Blood transfusion for the treatment of acute anaemia in inflammatory bowel disease and other digestive diseases

Association of miR-338-3p with survival outcomes in gastric cancer patients who received peri-operative blood transfusion

BACKGROUND

Perioperative blood transfusion (BT) is frequent in the treatment of gastric cancer (GC), but its effects on the prognosis of GC remains controversial. In this study, we aimed to further confirm the relationship of perioperative BT with GC overall survival and to evaluate the predictive value of microRNA-338-3p (miR-338-3p) for the prognosis of GC patients who received perioperative BT.

METHODS

Clinical data and serum samples were collected and analyzed from 246 patients with GC. Five-year follow-up survival information was assessed by Kaplan-Meier survival analysis. miR-338-3p relative expression was assessed by RT-qPCR, and its relationship with the prognosis of GC patients, who received perioperative BT, was evaluated using Kaplan-Meier curves and Cox regression analysis.

RESULTS

GC patients received perioperative BT had poor 5 year survival than those without BT. In patients received BT, miR-338-3p expression was higher in survival cases than died population and high miR-338-3p was independently associated with better overall survival prognosis.

CONCLUSION

Perioperative BT is related with poor prognosis in GC patients and miR-338-3p may be a prognostic biomarker for GC patients received perioperative BT. BT in perioperative GC patients should be cautious, especially for those with low levels of miR-338-3p.

Diagnosis and management of anemia in pediatric inflammatory bowel diseases: Clinical practice guidelines on behalf of the SIGENP IBD Working group

Anemia is one of the most frequent extra-intestinal manifestations of inflammatory bowel disease. Insidious onset, variability of symptoms and lack of standardized screening practices may increase the risk of underestimating its burden in children with IBD. Despite its relevance and peculiarity in everyday clinical practice, this topic is only dealt with in a few documents specifically for the pediatric field. The aim of the current guidelines is therefore to provide pediatric gastroenterologists with a practical update to support the clinical and therapeutic management of children with IBD and anemia. A panel of 19 pediatric gastroenterologists and 1 pediatric hematologist with experience in the field of pediatric IBD was agreed by IBD Working group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) to produce the present article outlining practical clinical approaches to the pediatric patient with IBD and anemia. The levels of evidence and recommendations have been defined for each part of the statement according to the GRADE system.

Development and validation of a novel nomogram to predict the risk of the prolonged postoperative length of stay for lumbar spinal stenosis patients

BACKGROUND

Lumber spinal stenosis (LSS) is the increasingly reason for spine surgery for elder patients since China is facing the fastest-growing aging population. The aim of this research was to create a model to predict the probabilities of requiring a prolonged postoperative length of stay (PLOS) for lumbar spinal stenosis patients, minimizing the healthcare burden.

METHODS

A total of 540 LSS patients were enrolled in this project. The outcome was a prolonged PLOS after spine surgery, defined as hospitalizations ≥ 75th percentile for PLOS, including the day of discharge. The least absolute shrinkage and selection operator (LASSO) was used to identify independent risk variables related to prolonged PLOS. Multivariable logistic regression analysis was utilized to generate a prediction model utilizing the variables employed in the LASSO approach. The receiver operating characteristic (ROC) curve's area under the curve (AUC) and the calibration curve's respective curves were used to further validate the model's calibration with predictability and discriminative capabilities. By using decision curve analysis, the resulting model's clinical effectiveness was assessed.

RESULTS

Among 540 individuals, 344 had PLOS that was within the usual range of P75 (8 days), according to the interquartile range of PLOS, and 196 had PLOS that was above the normal range of P75 (prolonged PLOS). Four variables were incorporated into the predictive model, named: transfusion, operation duration, blood loss and involved spine segments. A great difference in clinical scores can be found between the two groups (P < 0.001). In the development set, the model's AUC for predicting prolonged PLOS was 0.812 (95% CI: 0.768-0.859), while in the validation set, it was 0.830 (95% CI: 0.753-0.881). The calibration plots for the probability showed coherence between the expected probability and the actual probability both in the development set and validation set respectively. When intervention was chosen at the potential threshold of 2%, analysis of the decision curve revealed that the model was more clinically effective.

CONCLUSIONS

The individualized prediction nomogram incorporating five common clinical features for LSS patients undergoing surgery can be suitably used to smooth early identification and improve screening of patients at higher risk of prolonged PLOS and minimize health care.

Ironing It All Out: A Comprehensive Review of Iron Deficiency Anemia in Inflammatory Bowel Disease Patients

Iron deficiency anemia affects approximately 45% of patients with inflammatory bowel disease (IBD), negatively impacts the quality of life in this patient population, and significantly burdens our healthcare system. The pathogenesis of iron deficiency in IBD patients is multifactorial, including intestinal bleeding, malabsorption, and inadequate oral intake. Regular screening and diagnosis in these patients are imperative, and often patients have mixed iron deficiency anemia and anemia of chronic disease, especially in those with active inflammation. Iron may be replenished either orally or intravenously. While oral iron is safe, affordable, and easy to administer, patients often suffer from intolerable gastrointestinal side effects, and particularly in IBD patients, oral iron may increase inflammation and contribute to flares. Therefore, although it is substantially underused, intravenous (IV) iron is considered first-line treatment for patients with active disease, severe anemia, oral iron intolerance, and erythropoietin requirements. Several IV iron formulations are available, and iron sucrose and ferric carboxymaltose are the most frequently used and well studied in patients with IBD. However, iron isomaltoside could potentially become a popular choice among providers given its safety, efficacy, and convenience. Overall, screening, diagnosis, and treatment of iron deficiency anemia are important in patients with IBD. Individual patient characteristics, risks, and benefits, and advantages and disadvantages, should be considered when determining the best route and formulation for iron repletion.

Indications and hemoglobin thresholds for red blood cell transfusion and iron replacement in adults with gastrointestinal bleeding: An algorithm proposed by gastroenterologists and patient blood management experts

Gastrointestinal (GI) bleeding is associated with considerable morbidity and mortality. Red blood cell (RBC) transfusion has long been the cornerstone of treatment for anemia due to GI bleeding. However, blood is not devoid of potential adverse effects, and it is also a precious resource, with limited supplies in blood banks. Nowadays, all patients should benefit from a patient blood management (PBM) program that aims to minimize blood loss, optimize hematopoiesis (mainly by using iron replacement therapy), maximize tolerance of anemia, and avoid unnecessary transfusions. Integration of PBM into healthcare management reduces patient mortality and morbidity and supports a restrictive RBC transfusion approach by reducing transfusion rates. The European Commission has outlined strategies to support hospitals with the implementation of PBM, but it is vital that these initiatives are translated into clinical practice. To help optimize management of anemia and iron deficiency in adults with acute or chronic GI bleeding, we developed a protocol under the auspices of the Spanish Association of Gastroenterology, in collaboration with healthcare professionals from 16 hospitals across Spain, including expert advice from different specialties involved in PBM strategies, such as internal medicine physicians, intensive care specialists, and hematologists. Recommendations include how to identify patients who have anemia (or iron deficiency) requiring oral/intravenous iron replacement therapy and/or RBC transfusion (using a restrictive approach to transfusion), and transfusing RBC units 1 unit at a time, with assessment of patients after each given unit (i.e., “don’t give two without review”). The advantages and limitations of oral versus intravenous iron and guidance on the safe and effective use of intravenous iron are also described. Implementation of a PBM strategy and clinical decision-making support, including early treatment of anemia with iron supplementation in patients with GI bleeding, may improve patient outcomes and lower hospital costs.

Anemia in Children With Inflammatory Bowel Disease: A Position Paper by the IBD Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition

Anemia is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD). It can be asymptomatic or associated with nonspecific symptoms, such as irritability, headaches, fatigue, dizziness, and anorexia. In IBD patients, the etiology of anemia is often multifactorial. Various causes include iron deficiency, anemia of inflammation and chronic disease, vitamin deficiencies, hemolysis, or myelosuppressive effect of drugs. Anemia and iron deficiency in these patients may be underestimated because of their insidious onset, lack of standardized screening practices, and possibly underappreciation that treatment of anemia is also required when treating IBD. Practitioners may hesitate to use oral preparations because of their intolerance whereas intravenous preparations are underutilized because of fear of adverse events, availability, and cost. Several publications in recent years have documented the safety and comparative efficacy of various intravenous preparations. This article reviews management of anemia in children with IBD, including diagnosis, etiopathogenesis, evaluation of a patient, protocol to screen and monitor patients for early detection and response to therapy, treatment including parenteral iron therapy, and newer approaches in management of anemia of chronic disease. This report has been compiled by a group of pediatric gastroenterologists serving on the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) IBD committee, in collaboration with a pediatric hematologist, pharmacist, and a registered dietician who specializes in pediatric IBD (IBD Anemia Working Group), after an extensive review of the current literature. The purpose of this review is to raise awareness of under-diagnosis of anemia in children with IBD and make recommendations for screening, testing, and treatment in this population.

Trends in Anemia, Iron, Therapy, and Transfusion in Hospitalized Pediatric Patients with Inflammatory Bowel Disease

OBJECTIVE

To evaluate trends in diagnosis and management of iron deficiency anemia using a large national children's hospital database in pediatric patients admitted with inflammatory bowel disease (IBD).

STUDY DESIGN

In this retrospective multicenter cohort study, we used the Pediatric Health Information System de-identified administrative database. Patients age <21 years with ≥2 admissions with International Classification of Disease, Ninth Revision and Tenth Revision codes for Crohn's disease or ulcerative colitis from 2012 to 2018 were included. We extracted data regarding diagnoses of anemia and/or iron deficiency, and receipt of oral iron, intravenous (IV) iron, and/or blood transfusion. Data were analyzed descriptively.

RESULTS

We identified 8007 unique patients meeting study criteria for a total of 28 260 admissions. The median age at admission was 15.4 years. A diagnosis of anemia was documented in 29.8% of admissions and iron studies were performed in 12.6%. IV iron was given in 6.3% of admissions and blood transfusions in 7.4%. The prevalence of the diagnosis of anemia among IBD admissions increased from 24.6% in 2012 to 32.4% in 2018 (P < .0001). There was a steady increase in the proportion of IBD admissions that used IV iron, from 3.5% in 2012 to 10.4% in 2018 (P < .0001), and the proportion of admissions with red cell transfusions decreased over time from 9.4% to 4.4% (P < .0001).

CONCLUSIONS

Iron deficiency anemia is prevalent among pediatric patients with IBD admitted to US children's hospitals. From 2012 to 2018, there was an increase in the use of inpatient IV iron for the treatment of iron deficiency anemia and a decrease in transfusions.

[Management of anemia in patients with inflammatory bowel disease]

Anemia is one of the commonest extraintestinal manifestations of inflammatory bowel disease (IBD). The pathogenesis of anemia in IBD is complex but iron deficiency combined with inflammation is the most common factor related to the development of anemia. However, other causes such as vitamin B12 and folate deficiency, hemolysis, myelosuppression and drug also should not be overlooked. In addition to ferritin, inflammatory markers and new biochemical parameters such as hepcidin and ferritin index are being tested as diagnostic a tool. First step for treatment is disease activity control and iron supplementation. Although oral iron is widely used, intravenous iron therapy should be considered in patients who are intolerant to oral iron therapy, have severe and refractory anemia or are in active disease state. Recently, new intravenous iron formulations have been introduced and due to their safety and easy usage, they have become the standard treatment modality for managing anemia in IBD. Erythropoietin and transfusion can be considered in specific situations. Vitamin B12 and folate supplementation is also important in patients who are deficient of these micronutrients. Since anemia in IBD patients could significantly influence the disease outcome, further studies and standard guideline for IBD are needed.

Renal and Gastrointestinal Considerations in Joint Replacement Surgery

Renal and gastrointestinal diseases affect a significant portion of the general population. The process of decision making regarding surgical clearance and pre-operative management of the various complexities and medical conditions associated with these diseases hence becomes crucial. To optimize postoperative outcomes, the considerations for the care of this patient population revolve around effective management of hemostasis and electrolyte status. This subset of conditions is uniquely important with regard to the negative impact of improper administration of medications and perioperative care on patients' prognoses. A thorough understanding and knowledge of standards of care and treatment guidelines for patients with renal dysfunction and gastrointestinal disease assures comprehensive preoperative planning and surgical clearance. This may ultimately lead to improvement of surgical outcomes and potential decrease in postoperative morbidity and mortality.

High risk of transfusion-induced alloimmunization of patients with inflammatory bowel disease

BACKGROUND

Anemia is highly prevalent in inflammatory bowel disease patients, and red blood cell transfusion is often indicated already at reproductive age. Both transfusion and pregnancy may induce red cell alloantibodies, potentially complicating further transfusions and pregnancies. As recent evidence suggests that inflammation may promote red cell antibody induction, the alloimmunization risk of these patients after allogenic erythrocyte exposure was investigated.

METHODS

Red cell alloantibody status and clinical data were analyzed in 193 inflammatory bowel disease patients with a history of transfusion or pregnancy, and compared with transfused controls with noninflammatory diseases (n=357).

RESULTS

In transfused patients with inflammatory bowel disease, a 2.5-fold-increased red cell antibody prevalence was found (10/119, 8.4%), compared with transfused sex-matched controls with noninflammatory diseases (12/357, 3.4%; P=.023). Patients with inflammatory bowel disease had fewer transfusions (mean 3.0 vs 4.2, P=.003) but higher C-reactive protein levels during transfusion than controls (mean 8.4 vs 5.4 mg/dL, P <.001). The red cell antibodies of inflammatory bowel disease patients were clinically significant, directed against different Rh, Kell, Duffy, or Lutheran blood group antigens, and associated with higher number of transfusions (odds ratio 1.57; 95% confidence interval, 1.03-2.39). Conversely, immunomodulatory therapy during transfusion showed negative association (odds ratio 0.12; 95% confidence interval, 0.02-0.61). Only 1.4% of inflammatory bowel disease patients with pregnancy alone had antibodies.

CONCLUSIONS

Patients with inflammatory bowel disease exhibited a very high risk of transfusion-induced red cell alloimmunization, possibly potentiated by inflammation. Aside from a restrictive transfusion strategy, the implementation of prophylactic blood group phenotype matching of red cell concentrates (not only for ABO and RhD but also RhCcEe, Kell, Kidd, Duffy) could prevent antibody induction and associated complications in these patients.

Anemia and transfusion therapy: an update

Anemia is one of the most prevalent diseases in the general population and is a very frequently found condition in medical and surgical patients in all medical specialties. A good evaluation of its clinical impact and its therapeutic possibilities is essential. Allogenic blood transfusion is a useful procedure in anemia management, although it has important adverse effects. It is the responsibility of the clinician to know and to take into account all the available alternatives for the treatment of anemia. Blood transfusions, erythropoiesis-stimulating agents, iron therapy (oral and endovenous) and other therapeutic alternatives must be rationally used, in accordance with the currently available clinical evidence. This review article summarizes some epidemiological characteristics of anemia, its clinical evaluation and the main therapeutic possibilities based on the present knowledge, placing special emphasis on the critically ill patient.

Review article: the optimal medical management of acute severe ulcerative colitis

BACKGROUND

Management of acute severe ulcerative colitis (UC) is a clinical challenge, with a mortality rate of approximately 1-2%. The traditional management with intravenous corticosteroids has been modified by introduction of ciclosporin and more recently, infliximab.

AIM

To provide a detailed and comprehensive review of the medical management of acute severe UC.

METHODS

PubMed and recent conference abstracts were searched for articles relating to treatment of acute severe UC.

RESULTS

Two-thirds of patients respond to intravenous steroids in the short term. In those who fail steroids, low-dose intravenous ciclosporin at 2 mg/kg/day is effective. Approximately 75% and 50% of patients treated with ciclosporin avoid colectomy in the short and long-terms, respectively. Long-term outcome of ciclosporin therapy is improved by introduction of azathioprine on discharge from hospital, together with oral ciclosporin as a bridging therapy. Controlled data show that infliximab is effective as rescue therapy for acute severe UC and the effect appears to be durable, although longer-term follow-up data are needed.

CONCLUSIONS

Both ciclosporin and infliximab have demonstrated efficacy as rescue medical therapies in patients with acute severe UC, but surgery needs to be considered if there is failure to improve or clinical deterioration.

[Anemia and transfusion therapy: an update]

Anemia is one of the most prevalent diseases in the general population and is a very frequently found condition in medical and surgical patients in all medical specialties. A good evaluation of its clinical impact and its therapeutic possibilities is essential. Allogenic blood transfusion is a useful procedure in anemia management, although it has important adverse effects. It is the responsibility of the clinician to know and to take into account all the available alternatives for the treatment of anemia. Blood transfusions, erythropoiesis-stimulating agents, iron therapy (oral and endovenous) and other therapeutic alternatives must be rationally used, in accordance with the currently available clinical evidence. This review article summarizes some epidemiological characteristics of anemia, its clinical evaluation and the main therapeutic possibilities based on the present knowledge, placing special emphasis on the critically ill patient.

Intravenous iron in digestive diseases: a clinical (re)view

Intravenous iron has been considered dangerous by many clinicians. In the last two decades, considerable experience has been gained with new formulations in different clinical settings. Data from clinical trials, observational studies, and postmarketing surveillance studies demonstrate that intravenous iron is safe and effective to treat iron deficiency and iron deficiency anaemia. Iron deficiency is particularly common in many digestive diseases: oral iron often fails while transfusions are not without considerable risks. In particular, in inflammatory bowel diseases, there is enough evidence to recommend intravenous iron in moderate-to-severe iron deficiency anaemia, in intolerance to oral iron, and in patients needing quick recovery (pre-operative setting). New formulations make treatment even easier and more convenient. Recent guidelines are available for inflammatory bowel diseases, and new guidelines in acute and chronic gastrointestinal bleeding are needed.