Prevalence and treatment of anemia and secondary iron overload in patients with a myelodysplastic syndrome: real-world data from a multicenter cohort study

BACKGROUND

anemia is the most common finding in patients with a myelodysplastic syndrome (MDS). Repetitive red blood cell (RBC) transfusions and disease-related low hepcidin levels induce secondary iron overload. Real-world data on the prevalence and treatment strategies of anemia and secondary iron overload in MDS patients, is limited.

METHODS

three years of data on MDS diagnosis, anemia and ferritin management was collected in 230 MDS patients from seven non-academic hospitals in the Netherlands. Descriptive statistics and linear mixed models were used to analyze the data.

RESULTS

transfusion dependent (TD) patients (n=49) needed 1-3 RBC transfusions per month. Serum hemoglobin remained stable in both TD and transfusion-independent (TI) patients over 3 years. In the TD patients, serum ferritin increased 63 pmol/L/month. Overall, 19 (39%) were diagnosed with secondary hemochromatosis, of which 13 (68%) received chelation therapy with a heterogeneous response.

CONCLUSIONS

mean hemoglobin remains stable over time in both TD and TI MDS patients. Approximately 40% of TD patients develop secondary hemochromatosis. Treatment and monitoring of secondary hemochromatosis as well as the response on chelation therapy varies substantially.

The interplay between GPIb/IX antibodies, platelet hepatic sequestration, and TPO levels in patients with chronic ITP

Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder with an incompletely understood pathophysiology but includes platelet-clearance in the spleen and liver via T cells and/or platelet autoantibodies. Strikingly, thrombopoietin (TPO) levels remain low in ITP. Platelet-glycoprotein (GP)Ibα has been described to be required for hepatic TPO generation; however, the role of GPIb antibodies in relation to platelet hepatic sequestration and TPO levels, with consideration of platelet counts, remains to be elucidated. Therefore, we examined 53 patients with chronic and nonsplenectomized ITP for whom we conducted indium-labeled autologous platelet scintigraphy and measured platelet antibodies and TPO levels. Upon stratification toward the severity of thrombocytopenia, no negative association was observed between GPIb/IX antibodies and TPO levels, suggesting that GPIb/IX antibodies do not inhibit or block TPO levels. Surprisingly, we observed a positive association between GPIb/IX antibody levels and TPO levels and GPIb/IX antibodies and platelet hepatic sequestration in patients with severe, but not mild or moderate, thrombocytopenia. In addition, platelet hepatic sequestration and TPO levels were positively associated. This collectively indicates that GPIb/IX antibodies may be associated with increased platelet hepatic sequestration and elevated TPO levels in patients with severe thrombocytopenic ITP; however, further research is warranted to elucidate the pathophysiologic mechanisms.

Hemoglobin modulation affects physiology and patient reported outcomes in anemic and non-anemic subjects: An umbrella review

Background: An abnormal hemoglobin concentration has a substantial effect on a person's quality of life and physiology. Lack of tools that effectively evaluate hemoglobin-related outcomes leads to uncertainty regarding optimal hemoglobin levels, transfusion thresholds and treatment targets. We therefore aim to summarize reviews that assess the effects of hemoglobin modulation on the human physiology at various baseline hemoglobin levels, and identify gaps in existing evidence. Methods: We conducted an umbrella review of systematic reviews. PubMed, MEDLINE (OVID), Embase, Web of Science, Cochrane Library and Emcare were searched from inception to the 15th of April 2022 for studies that reported on physiological and patient reported outcomes following a hemoglobin change. Results: Thirty-three reviews were included of which 7 were scored as of high quality and 24 of critically low quality using the AMSTAR-2 tool. The reported data generally show that an increase in hemoglobin leads to improvement of patient reported and physical outcomes in anaemic and non-anaemic subjects. At lower hemoglobin levels, the effect of a hemoglobin modulation on quality of life measures appears more pronounced. Conclusion: This overview has revealed many knowledge gaps due to a lack of high-quality evidence. For chronic kidney disease patients, a clinically relevant benefit of increasing the hemoglobin levels up until 12 g/dL was found. However, a personalized approach remains necessary due to the many patient-specific factors that affect outcomes. We strongly encourage future trials to incorporate physiological outcomes as objective parameters together with subjective, but still very important, patient reported outcome measures.

Clinical practice for outpatients that are chronically red cell dependent: A survey in the Netherlands

BACKGROUND AND OBJECTIVES

Limited data are available to guide physicians on how to determine the red blood cell (RBC) transfusion regimen in chronically transfusion-dependent patients. The lack of clarity on thresholds and targets to be used for transfusion could easily result in either under or over transfusion in these patients. The aim of our survey is to investigate (1) transfusion thresholds; (2) number of RBC units given per transfusion episode; (3) interval between transfusions and (4) patient factors, like decreased cardiac function modulating the former.

MATERIALS AND METHODS

We sent a web-based 44-question survey to members of the Dutch Haematology Association.

RESULTS

Fifty physicians responded between June and October 2020 (response rate 30%), well-distributed between community and academic hospitals. A wide variation in transfusion strategies was reported: Most patients have transfused 1-2 RBC units (range: 0-3 units) every 2-4 weeks (range: 1-12 weeks) with a median threshold of 8.0 g/dl ranging from 6.4 to 9.6 g/dl. Patient-specific clinical factors that are most frequently reported to influence the transfusion strategy are angina pectoris, cardiac failure and dyspnoea, softer parameters that are of influence are the quality of life and self-sustainability.

CONCLUSION

The results of this survey indicate a broad variation in RBC transfusion strategies in Dutch patients with chronic transfusion dependency. While the current variation in transfusion strategies may be unavoidable in an individualized approach, randomized trials and better defined usable parameters to evaluate the effect of transfusion strategies are required to reach a consensus on how to determine the transfusion strategy.

Guideline development for prevention of transfusion-associated graft-versus-host disease: reduction of indications for irradiated blood components after prestorage leukodepletion of blood components

Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare, commonly fatal complication of transfusion preventable by irradiation of blood units. The revision of the Dutch transfusion guideline addressed the question whether irradiation is still necessary if blood components are prestorage leukodepleted. We searched for published cases of TA-GVHD following transfusion of prestorage leukodepleted blood and through contacting haemovigilance systems. Six presumed cases were found, dating from 1998 to 2013. Four out of six patients had received one or more non-irradiated units despite recognised indications for irradiated blood components. In the countries providing information, over 50 million prestorage leukodepleted, non-irradiated, non-pathogen-reduced cellular components were transfused in a 10-year period. Potential benefits of lifting indications for irradiation were considered. These include reduced irradiation costs (€ 1.5 million annually in the Netherlands) and less donor exposure for neonates. Findings were presented in an invitational expert meeting. Recommendations linked to human leukocyte antigen similarity between donor and recipient or intra-uterine transfusion were left unchanged. Indications linked to long-lasting deep T-cell suppression were defined with durations of 6 or 12 months after end of treatment (e.g. autologous or allogeneic stem cell transplantation). Need for continued alertness to TA-GVHD and haemovigilance reporting of erroneous non-irradiated transfusions was emphasised.

Autologous platelet scintigraphy and clinical outcome of splenectomy in immune thrombocytopenia: A systematic review and meta-analysis

Autologous platelet sequestration pattern is associated with post-splenectomy platelet response in patients with immune thrombocytopenia (ITP). However, published results are contradictory, and have not been systematically reviewed. Our aim is to systematically review and meta-analyse the association between sequestration pattern and post-splenectomy platelet response. Articles were selected from MEDLINE when they a) included ITP patients, b) performed scintigraphy, and c) included post-splenectomy platelet response. The 23 included studies (published between 1969-2018) represented 2966 ITP-patients. Response to splenectomy occurred most frequently in patients with a splenic pattern (87.1 % in splenic versus 47.1 % in mixed and 25.5 % in hepatic patterns). A pooled analysis of 8 studies showed an odds ratio of 14.21 (95 % CI: 3.65-55.37) for platelet response in the splenic versus the hepatic group. Our findings indicate that a splenic sequestration pattern is associated with better response after splenectomy. Platelet sequestration patterns may be useful in the clinical decision-making regarding splenectomy.

Treatment strategies for polycythemia vera: Observations in a Dutch "real-world" cohort study

OBJECTIVES

Assessment of "real-world" treatment strategies and outcome in Dutch polycythemia vera (PV) patients.

METHODS

Retrospective chart review in 150 patients with PV (WHO 2008 diagnostic criteria) from 10 major non-academic hospitals in the Netherlands.

RESULTS

Patients (median age 64 years, 49% male) frequently had cardiovascular risk factors (56%) and prior vascular events (31%). About 70% of patients were high-risk, based on ELN criteria. However, the majority of patients were treated with phlebotomies alone (55%). Cytoreduction with hydroxyurea (HU) was received by 44% as part of their initial therapy, with or without phlebotomies. The time to achieve the 45% hematocrit target was shortest in patients treated with phlebotomies with or without HU (125 ± 99 and 197 ± 249 days, respectively) compared to patients treated with only HU (232 ± 216 days). Leukocyte and platelet levels were lower in HU-treated patients, and ELN response targets were more often reached. During the median follow-up period of 4.1 years, 14 patients (9%) suffered a thrombotic vascular event.

CONCLUSIONS

In Dutch clinical practice, there is major clinical variation in treatment strategies for PV. Phlebotomizing patients shorten the time to achieve hematocrit control, while HU better controls platelet and leukocyte levels. The thrombotic vascular event rate remains clinically significant.

Transition from fresh frozen plasma to solvent/detergent plasma in the Netherlands: comparing clinical use and transfusion reaction risks

Plasma transfusion is indicated for replenishment of coagulative proteins to stop or prevent bleeding. In 2014, the Netherlands switched from using ~300mL fresh frozen plasma (FFP) units to using 200mL Omniplasma, a solvent/detergent treated pooled plasma (SD plasma), units. We evaluated the effect of the introduction of SD plasma on clinical plasma use, associated bleeding, and transfusion reaction incidences. Using diagnostic data from six Dutch hospitals, national blood bank data, and national hemovigilance data for 2011 to 2017, we compared the plasma/red blood cell (RBC) units ratio (f) and the mean number of plasma and RBC units transfused for FFP (~300mL) and SD plasma (200mL) for various patient groups, and calculated odds ratios comparing their associated transfusion reaction risks. Analyzing 13,910 transfusion episodes, the difference (Δf = f_{SD -} f_FFP) in mean plasma/RBC ratio (f) was negligible (Δf_{entire_cohort} = 0.01 [95% confidence interval (CI): −0.02 - 0.05]; P=0.48). SD plasma was associated with fewer RBC units transfused per episode in gynecological (difference of mean number of units −1.66 [95% CI: −2.72, −0.61]) and aneurysm (−0.97 [−1.59, −0.35]) patients. SD plasma was further associated with fewer anaphylactic reactions than FFP (odds ratio 0.37 [0.18, 0.77; P<0.01]) while the differences for most transfusion reactions were not statistically significant. SD plasma units, despite being one third smaller in volume than FFP units, are not associated with a higher plasma/RBC ratio. SD plasma is associated with fewer anaphylactic reactions than FFP plasma/RBC units ratio.

International haemovigilance: what have we learned and what do we need to do next?

The International Haemovigilance Network (IHN) defines haemovigilance as 'a set of surveillance procedures covering the whole transfusion chain (from the collection of blood and its components to the follow-up of recipients), intended to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products, and to prevent their occurrence or recurrence'. IHN, the International Society of Blood Transfusion and World Health Organization work together to support both developing and established haemovigilance systems. Haemovigilance systems provide valuable data on a range of adverse events related to blood donation and clinical transfusion, from donor syncopal events to transfusion-transmitted infections, immunological complications and the impact of human errors. Harmonised definitions for most adverse reactions have been developed and validated internationally. Definitions of pulmonary complications are again under review. Haemovigilance data have resulted in changes in policy, products and practice, and can complement and inform clinical audit and research, leading to improved blood donor safety, optimised product use and better clinical outcomes after transfusion. However, more work is needed. Not all countries have haemovigilance systems in place. More robust data and careful analysis are required to improve the understanding of the causes, occurrence and clinical outcomes of these events. Wider dissemination of results will facilitate health policy development internationally, and implementation of haemovigilance recommendations will support further important progress in blood safety.

Transfusion reactions after transfusion of platelets stored in PAS-B, PAS-C, or plasma: a nationwide comparison

BACKGROUND

Platelets (PLTs) stored in PLT additive solution (PAS) are associated with fewer allergic reactions than plasma-stored PLTs. However, earlier studies could not provide conclusive evidence on febrile reactions and did not analyze other transfusion reactions separately due to limited sample size. We therefore compared incidences of all transfusion reactions of PAS-B-PLTs, PAS-C-PLTs, and plasma-PLTs.

STUDY DESIGN AND METHODS

In this observational study, all transfusion reactions reported to the national hemovigilance office of the Netherlands from 2006 to 2015 were included.

RESULTS

During the study period, a total of 2407 transfusion reactions after PLT transfusions were reported. In that period 553,267 pooled buffy coat-derived PLT units were issued, of which 83,884 were stored in PAS-B, 45,728 in PAS-C, and 423,655 in plasma. Regarding transfusion-related circulatory overload, transfusion-related acute lung injury, and "other reactions" no significant differences were observed between the PLT products. When PAS-B-PLT transfusions were compared to plasma-PLT transfusions, the overall relative risk (RR; 95% confidence interval [CI]) of transfusion reactions was 0.99 (0.88-1.11); for allergic and febrile nonhemolytic transfusion reactions (FNHTRs) it was 0.66 (0.55-0.80) and 1.54 (1.27-1.86), respectively. When PAS-C-PLTs were compared to plasma-PLTs, the RR (95% CI) was 0.56 (0.46-0.68) for all transfusion reactions, 0.38 (0.28-0.52) for allergic reactions, and 0.82 (0.59-1.13) for FNHTRs. When PAS-C-PLTs were compared to PAS-B-PLTs, for all reactions the RR (95% CI) was 0.56 (0.45-0.70) for allergic reactions 0.58 (0.40-0.82), and for FNHTRs 0.53 (0.37-0.75).

CONCLUSIONS

PAS-C-PLTs are associated with fewer transfusion reactions compared to plasma-PLTs and compared to PAS-B-PLTs.

Storage medium of platelet transfusions and the risk of transfusion-transmitted bacterial infections

BACKGROUND

Transfusion-transmitted bacterial infections (TTBIs) are among the most concerning risks of transfusion of platelet (PLT) concentrates. Storage medium influences bacterial growth dynamics and thereby the sensitivity of screening tests for bacterial contamination.

STUDY DESIGN AND METHODS

The aim of this study was to quantify the association of storage media with the incidence of TTBIs after transfusion of PLT concentrates. In the Netherlands, the choice of storage medium is determined solely by geographic location of the hospital. We compared types of storage medium of all reported cases of TTBIs after transfusion of a PLT concentrate with types of storage medium of all produced PLT concentrates in the Netherlands from 2003 to 2014.

RESULTS

Fourteen cases of TTBIs were reported, of which 57.1% received a PLT concentrate stored in PLT additive solution (PAS) and 42.9% a PLT concentrate stored in plasma. Of all produced PLT concentrates 22.3% were stored in PAS and 77.7% in plasma. The relative risk of TTBI after transfusion of a PAS-stored PLT concentrate was 4.63 (95% confidence interval [CI], 1.4-16.2) compared to transfusion of a plasma-stored PLT concentrate. The incidence of TTBIs was 22.2 per million (95% CI, 12.1-37.2 per million) transfused buffy coat PLT concentrates.

CONCLUSION

Transfusion of PAS-stored PLT concentrates is associated with a fourfold increased incidence of TTBIs, compared to plasma-stored PLT concentrates.

Successful treatment of a noninhibitory antibody-mediated acquired factor X deficiency in a patient with marginal-zone lymphoma

Prolonged clotting times were observed in a patient with spontaneous hemorrhage. Analysis showed severe factor X deficiency due to clearance by a noninhibitory antibody. Lymphadenopathy identified on imaging led to diagnosis of marginal B-cell lymphoma. Treatment of lymphoma with rituximab and chlorambucil resulted in complete disappearance of the bleeding disorder.

A phase 2, randomized, double-blind, multicenter study comparing siltuximab plus best supportive care (BSC) with placebo plus BSC in anemic patients with International Prognostic Scoring System low- or intermediate-1-risk myelodysplastic syndrome

Interleukin-6 (IL-6) may play an important role in the pathophysiology of anemia of inflammation associated with myelodysplastic syndrome (MDS). This double-blind, placebo-controlled, phase 2 study assessed the efficacy and safety of siltuximab, a chimeric anti-IL-6 monoclonal antibody, in patients with low- and intermediate-1-risk MDS who require transfusions for MDS anemia. Patients were randomized in a 2:1 ratio to siltuximab 15 mg kg(-1) every 4 weeks + best supportive care (BSC) or placebo + BSC for 12 weeks. The primary endpoint was reduction in red blood cell (RBC) transfusions to treat MDS anemia, defined as ≥50% relative decrease and ≥2-unit absolute decrease in RBC transfusions. Fifty and 26 patients were randomized to the siltuximab and placebo groups, respectively. The study did not meet its prespecified hypothesis, with six (12%) patients in the siltuximab group and one (3.8%) in the placebo group having reductions in RBC transfusions (P = 0.271). At the time of the planned futility analysis, the prespecified cutoff criteria were not met, and the study was terminated early due to lack of efficacy. No unexpected safety findings were observed. In conclusion, compared to placebo, treatment with siltuximab did not reduce RBC transfusions in transfusion-dependent patients with low- and intermediate-1-risk MDS. Future studies might explore siltuximab in patients with less iron overload and with elevated IL-6 levels and/or using higher doses for MDS.

Helicobacter pylori infection is not correlated with subclinical thrombocytopenia: a cross-sectional study

In a small percentage of patients with immune thrombocytopenia (ITP), H. pylori eradication has a positive effect on platelet counts. Whether H. pylori infection is associated with a lower thrombocyte count in persons without clinical ITP is unknown. We performed a cross-sectional study to compare thrombocyte count between H. pylori infected (n=108) and H. pylori non-infected patients (n=600) who underwent a diagnostic gastroscopy. The mean thrombocyte count in H. pylori negative patients was 257 × 10(9)/l, in H. pylori positive patients 252 × 10(9)/l (mean difference 5 × 10(9)/l, 95% CI: -23 to 14). Subgroup analysis did not show significant differences either. In the patient group without apparent comorbidity, there were no subjects with thrombocyte counts <120. In 36 H. pylori positive patients in whom data post-eradication was available, platelet counts pre- and post-eradication were similar. In conclusion, this study could not demonstrate a lower thrombocyte count in H. pylori infected patients or in subgroups of H. pylori infected patients compared to non-infected subjects.

Quality validation of data in national haemovigilance systems in Europe: report of a survey on current state of practice

European Union member states must have national haemovigilance reporting of serious adverse reactions and events. We sent national competent authorities an email questionnaire about data validation. Responses were received from 23/27 countries. Nine previously had no national haemovigilance system. In 13 (57%), the serious adverse reactions and events can be verified. Coverage of blood establishments is documented in 20 systems (87%) and of hospitals in 15 systems (65%). Although all member states have implemented haemovigilance systems, there are currently wide variations in data quality assurance, not allowing comparisons between countries.

Variation between hospitals in rates of reported transfusion reactions: is a high reporting rate an indicator of safer transfusion?

BACKGROUND AND OBJECTIVES

It has been suggested that the rate of reported transfusion reactions is positively correlated with safety of the transfusion chain in a hospital. We evaluated this assumption in the Transfusion Reactions in Patients Dutch National Hemovigilance Office database taking reported incorrect blood component transfused as a proxy for unsafe transfusion.

METHODS

Reports from 2006 to 2010 and annual numbers of transfused blood components from the 103 hospitals were analysed. The rate of transfusion reactions per 1000 blood components was calculated per hospital. Logistic regression analysis was performed between reporting of at least one incorrect blood component and tertile of transfusion reaction rate.

RESULTS

Out of the 103 hospitals, 101 had complete data in some and 93 in all 5years. In all, 72 had reported at least one incorrect blood component transfused; this was associated with blood use level and also with rate of reported transfusion reactions: odds ratio 4·2 (95% confidence interval, 1·3-13·7) in the highest vs. the lowest tertile after adjustment for blood use level.

CONCLUSION

Hospitals in the Netherlands which report more transfusion reactions per 1000 units are also more likely to have reported incorrect blood component transfused. The data do not support that hospitals with a higher rate of transfusion reaction reports are safer.

Allo-exposure status and leucocyte antibody positivity of blood donors show a similar relation with TRALI

INTRODUCTION

The fraction of transfusion-related acute lung injury (TRALI) cases preventable by deferral of allo-exposed donors has previously been estimated, under the assumption this indirectly estimated the contribution of leucocyte antibodies to the occurrence of TRALI. Our aim was to estimate the fraction preventable by deferral of leucocyte antibody positive donors and to investigate the validity of allo-exposure as a marker for leucocyte antibodies.

METHODS

All donors involved in a series of previously published TRALI patients were tested for leucocyte antibodies. The observed number of antibody positive donors was compared to the expected number. From this comparison we estimated the contribution of leucocyte antibodies to the occurrence of TRALI and compared this to the previously reported estimate for allo-exposed donors.

RESULTS

Sixty-one TRALI patients were included. Of 288 involved donors 43 were expected and 67 were observed to be leucocyte antibody positive. The observed percentage of positive donors was 8.3% (95% confidence interval (CI): 5.1-11.5%) in excess of the expected. Overall 59% (95% CI: 34-85%) of TRALI cases was estimated to be preventable by the exclusion of all leucocyte antibody positive donors. For plasma-poor products this was 16% (95% CI: -5.0 to 36%).

CONCLUSIONS

These estimates were similar to those previously published for allo-exposed donors. This suggests allo-exposure status can effectively be used in donor deferral strategies.

Duration of meconium passage in preterm and term infants

BACKGROUND

First passage of stool after birth, meconium, is delayed in preterm infants compared to term infants. The difference in duration of meconium passage until transition to normal stools has however never been assessed in preterm and term infants.

HYPOTHESIS

Preterm infants have prolonged duration of passage of meconium (PoM) compared to term infants.

METHODS

Between August and November 2006, all infants born in an academic and non-academic hospital with gestational age (GA) 25-42 weeks and without metabolical, congenital diseases or gastrointestinal disorders, were included. Infants were divided into four groups: (A) GA < or =30 weeks; (B) GA between 31 and 34 weeks; (C) GA between 35 and 36 weeks; (D) GA > or = 37 weeks (term born).

RESULTS

A total of 198 infants (102 males); 32, 62, 33 and 71 infants in groups A, B, C and D, respectively, were included. With decreasing gestation a trend was found for delayed first PoM (p<0.001). Compared to term infants 79% (56/71), less preterm infants passed their first stool within 24 h after birth--group A: 44% (14/32); group B: 68% (42/62); and group C: 73% (24/33). With decreasing gestation a trend for prolonged PoM was found (p<0.001). The mean (SD) PoM duration was prolonged in group A: 7.8 days (2.5); group B: 4.3 days (2.4); and group C: 2.9 days (1.3) compared to term infants. Furthermore, PoM was associated with birth weights < or =2500 g (p = 0.03) and morphine therapy (p = 0.03). Duration of PoM was not associated with type of feeding, small for gestational age, large for gestational age or need for respiratory support.

CONCLUSION

PoM was not only delayed but also prolonged in preterm infants. Duration of PoM was associated with GA, birth weight and morphine therapy.

[Transfusion-related acute lung injury (TRALI) in the Netherlands in 2002-2005]

OBJECTIVE

To determine the number of reported cases of transfusion-related acute lung injury (TRALI) in the Netherlands in 2002-2005 and to determine how many cases were associated with incompatibility between leukocyte-reactive antibodies in the donor plasma and leukocytes or antigens in the recipient.

DESIGN

Retrospective national case review.

METHOD

Cases of TRALI reported in 2002-2005 were assessed according to the national clinical definition of TRALI, and the relationship between TRALI and transfusion was assessed. Additional clinical details were requested from the treating hospital as necessary. The results of leukocyte serological tests from donors and recipients were linked to clinical cases. For cases with positive leukocyte serological tests, the relevant blood components and the sex of the donor were recorded.

RESULTS

Of the 46 cases reported, 6 had insufficient information. 8 cases did not meet the definition or had another more likely diagnosis. There was a trend toward an increase in the number of reports: 12 cases were reported in 2005, corresponding with 1:60,000 blood components. Of the 40 evaluable cases, 32 (80%) met the definition of TRALI and were deemed to be definitely (n = 16), probably (n = 5) or possibly (n = 11) related to transfusion. Severity ranged from moderate to life-threatening, and there was one TRALI-related death. Leukocyte serology was fully investigated in 18 cases: 13 (72%) had leukocyte incompatibility and in 5 cases exclusively fresh frozen plasma from a female donor was implicated.

Efficacy of romiplostim in patients with chronic immune thrombocytopenic purpura: a double-blind randomised controlled trial

BACKGROUND

Chronic immune thrombocytopenic purpura (ITP) is characterised by accelerated platelet destruction and decreased platelet production. Short-term administration of the thrombopoiesis-stimulating protein, romiplostim, has been shown to increase platelet counts in most patients with chronic ITP. We assessed the long-term administration of romiplostim in splenectomised and non-splenectomised patients with ITP.

METHODS

In two parallel trials, 63 splenectomised and 62 non-splenectomised patients with ITP and a mean of three platelet counts 30x10(9)/L or less were randomly assigned 2:1 to subcutaneous injections of romiplostim (n=42 in splenectomised study and n=41 in non-splenectomised study) or placebo (n=21 in both studies) every week for 24 weeks. Doses of study drug were adjusted to maintain platelet counts of 50x10(9)/L to 200x10(9)/L. The primary objectives were to assess the efficacy of romiplostim as measured by a durable platelet response (platelet count > or =50x10(9)/L during 6 or more of the last 8 weeks of treatment) and treatment safety. Analysis was per protocol. These studies are registered with ClinicalTrials.gov, numbers NCT00102323 and NCT00102336.

FINDINGS

A durable platelet response was achieved by 16 of 42 splenectomised patients given romplostim versus none of 21 given placebo (difference in proportion of patients responding 38% [95% CI 23.4-52.8], p=0.0013), and by 25 of 41 non-splenectomised patients given romplostim versus one of 21 given placebo (56% [38.7-73.7], p<0.0001). The overall platelet response rate (either durable or transient platelet response) was noted in 88% (36/41) of non-splenectomised and 79% (33/42) of splenectomised patients given romiplostim compared with 14% (three of 21) of non-splenectomised and no splenectomised patients given placebo (p<0.0001). Patients given romiplostim achieved platelet counts of 50x10(9)/L or more on a mean of 13.8 (SE 0.9) weeks (mean 12.3 [1.2] weeks in splenectomised group vs 15.2 [1.2] weeks in non-splenectomised group) compared with 0.8 (0.4) weeks for those given placebo (0.2 [0.1] weeks vs 1.3 [0.8] weeks). 87% (20/23) of patients given romiplostim (12/12 splenectomised and eight of 11 non-splenectomised patients) reduced or discontinued concurrent therapy compared with 38% (six of 16) of those given placebo (one of six splenectomised and five of ten non-splenectomised patients). Adverse events were much the same in patients given romiplostim and placebo. No antibodies against romiplostim or thrombopoietin were detected.

INTERPRETATION

Romiplostim was well tolerated, and increased and maintained platelet counts in splenectomised and non-splenectomised patients with ITP. Many patients were able to reduce or discontinue other ITP medications. Stimulation of platelet production by romiplostim may provide a new therapeutic option for patients with ITP.

Experience with alemtuzumab in treatment of chronic lymphocytic leukaemia in the Netherlands

BACKGROUND

Alemtuzumab (MabCampath) is a monoclonal antibody against CD52, indicated as third-line treatment of chronic lymphocytic leukaemia (CLL). As most important side effect opportunistic infections are mentioned. It is, however, unknown whether these complications often lead to problems in general patient care in the Netherlands.

METHODS

To gain insight into the use and complications of alemtuzumab therapy, the alemtuzumab-treated CLL patients in 15 hospitals in the Netherlands were evaluated by means of a questionnaire.

RESULTS

In the period from 31 October 2001 until 17 November 2005, 27 patients with CLL or prolymphocytic leukaemia (PLL), RAI stage I to IV, Binet stage A to C, received 32 treatments with alemtuzumab. The time from diagnosis until start of alemtuzumab treatment was 6 +/- 4.5 years (mean +/- SD ). The treatment lasted 11 +/- 7 weeks. Of the treatments, 41% could be administered for the full 12 weeks. The most frequent adverse events were fever (72%), shivering (47%), fatigue (22%) and dyspnoea (16%). Haematological side effects consisted of leucopenia (75%), thrombocytopenia (44%), and anaemia (13%). Infectious complications occurred in 12 of 32 (38%) treatments: pneumonia (25%; of which one Pneumocystis carini pneumonia and four Aspergillus infections), sepsis (9%; of which one Listeria), herpes zoster (9%), herpes simplex (6%), CMV reactivation (6%), meningitis (3%) and Guillain Barre (3%). The overall response was 53%, with complete remission in 13%, partial remission in 41%, stable disease in 25% and progressive disease in 13%, and lasted for 8.3 +/- 7.3 months.

CONCLUSION

Treatment with alemtuzumab is often terminated prematurely, leading to a suboptimal treatment effect. Fear of severe uncontrollable opportunistic infections seems unjustified.

An open-label, unit dose-finding study of AMG 531, a novel thrombopoiesis-stimulating peptibody, in patients with immune thrombocytopenic purpura

Abstract The objective of this open label, phase 1-2, multicentre trial was to evaluate the safety of AMG 531, a novel thrombopoiesis-stimulating peptibody, and its effect on platelet counts in adults with immune thrombocytopenic purpura. Four patients were assigned to each of four unit-dose cohorts: 30, 100, 300 or 500 microg, administered subcutaneously on days 1 and 15 (or day 22 if the day 15 platelet count was >50 x 10(9)/l). Safety was assessed by adverse event (AE) monitoring, clinical laboratory studies and antibody assays. Platelet response was defined as a platelet count double the baseline value and between 50 and 450 x 10(9)/l. Sixteen patients (10 women) were enrolled. The 500-microg cohort was discontinued because the first patient's platelet count became unacceptably high. AEs were generally expected and mild or moderate; the most frequent was headache (eight of 16 patients). Two patients experienced serious AEs related to AMG 531 (severe headache and elevated serum lactic dehydrogenase; thrombocytopenia). Platelet responses occurred with all doses and with a dose equivalent to >/=1 microg/kg in eight of 11 patients. In summary, patients tolerated AMG 531 well at the doses tested. No anti-AMG or antithrombopoietin antibodies were detected. Doses equivalent to >/=1 microg/kg increased platelet counts.

T-lymphocyte reconstitution following rigorously T-cell-depleted versus unmodified autologous stem cell transplants

We compared the kinetics of T-cell recovery after extensive ex vivo and in vivo T-cell depleted autologous stem cell transplantation (SCT) for multiple sclerosis (MS; n=8) with unmodified SCT for hematological malignancies (HM; n=39). Both patient group showed a very protracted recovery of 'naive' CD4(+), 45R0(-) ( approximately CD45RA(+)) T-cells. Within the 'primed' CD4(+), 45R0(+) T-cells, the 'central memory' cells expressing the CD62L and CD27 markers were the slowest to recover. The repopulating T-cells were highly activated, as shown by increased expression of HLA-DR and the apoptosis marker CD95. The capability of CD4(+) and CD8(+) T-cells to produce IFN-gamma, IL-2 and TNF-alpha had reached normal ranges from 2 months post SCT onwards. Unexpectedly, the kinetics of T-cell recovery between 3 and 12 months post transplant was similar in T-depleted and unmodified SCT. Before SCT, the HM patients showed lymphopenia of all T-cell subsets, upregulated HLA-DR and CD95 expression and increased cytokine responses. We suggest that the similar kinetics of T-cell recovery in the two patient groups may be explained by the susceptibility to apoptosis of the activated CD4(+) T-cells in the autografts of the HM patients. This susceptibility to apoptosis would interfere with a swift and sustained CD4(+) T-cell regeneration post SCT.

[Transfusion reactions in patients: haemovigilance reports to the Dutch National Haemovigilance Office in 2003]

OBJECTIVE

National registration and analysis of unexpected side effects and incidents associated with blood transfusion (together termed 'transfusion reactions') in 2003 in order to arrive at recommendations to improve safety in the transfusion chain.

DESIGN

Observational

METHOD

A uniform national reporting form with definitions and a reporting manual were sent to all Dutch hospitals in the spring of 2003 with the request to report transfusion reactions retroactively to January 2003 to the Dutch National Haemovigilance Office 'Transfusion reactions in patients' (TRIP). TRIP is an independent organisation managed by representatives of professional societies that are involved in blood transfusion. Each hospital was given a reporting code. The reports were in principle voluntary and anonymous with regard to both the patient and the attending physician. Transfusion reactions were assessed for severity as well as for the level of probability with which they could be ascribed to the transfusion.

RESULTS

Reports were received from 82 (80%) of the hospitals; 9 hospitals informed the TRIP explicitly that there had been no transfusion reactions in 2003. A total of 267 reports were received. Of these, 803 (63%) were graded for severity and of these 803, 52 (6%) were grade 2 ('moderate to severe morbidity') or worse. In the categories involving possible infectious complications, there were 2 reports of bacterial contamination that were judged, on review, to be due 'with certainty' to the transfusion. 34 reports concerned transfusion of the wrong blood product, resulting in a total of 9 transfusion reactions (4 of grade 2). The total number of reports concerning 2003 was 1.6/1000 blood products.

CONCLUSION

The participation by the hospitals was high in the first year of national reporting, 2003. Most of the reports were of non-serious reactions known to be possible side effects of blood transfusion; 52 reports were rated as grade 2 or worse.

Feasibility of a restrictive red-cell transfusion policy for patients treated with intensive chemotherapy for acute myeloid leukaemia

Red-cell transfusions are required for symptomatic treatment of severe anaemia caused by intensive chemotherapy. Concerns about the transfusion-related complications, such as infections (e.g. the very low risk of human immunodeficiency virus (HIV)/hepatitis C virus (HCV) transmission and the risk of postoperative infections), haemolytic transfusion reaction, immunological effects and the costs, prompt a reevaluation of the transfusion practice. Retrospective analysis of prospectively collected data on 84 patients with acute myeloid leukaemia (AML), who were treated with combination chemotherapy between June 1, 1997 and December 7, 2001, was performed. The use of red-cell transfusions with a restrictive transfusion policy (haemoglobin = 7.2-8.8 g dL(-1), dependent on age and symptoms, n = 38) was compared with a more liberal transfusion trigger (haemoglobin = 9.6 g dL(-1), n = 46). The number of units transfused was recorded. Signs and symptoms of anaemia, chemotherapy-related effects and complications were investigated for both transfusion policies. The more restrictive transfusion policy led to a significant decrease of 11% of red blood cell (RBC) transfusions in patients with AML. No significant differences were found in the incidence of infections, number of platelet units transfused, bleeding complications, cardiac symptoms or response to chemotherapy. The more restrictive transfusion policy was feasible in this clinical setting, and it might be concluded that a restrictive transfusion policy is safe in supporting clinical patients treated with intensive chemotherapy for AML.

Efficacy and safety of darbepoetin alfa in anaemic patients with lymphoproliferative malignancies: a randomized, double-blind, placebo-controlled study

This phase 3, randomized, double-blind, placebo-controlled study was designed to evaluate the efficacy and safety of darbepoetin alfa in anaemic patients with lymphoproliferative malignancies. Patients (n = 344) with lymphoma or myeloma received darbepoetin alfa 2.25 microg/kg or placebo s.c., once weekly for 12 weeks. The percentage of patients achieving a haemoglobin response was significantly higher in the darbepoetin alfa group (60%) than in the placebo group (18%) (P < 0.001), regardless of baseline endogenous erythropoietin level. However, increased responsiveness was observed in patients with lower baseline erythropoietin levels. Darbepoetin alfa also resulted in higher mean changes in haemoglobin than placebo from baseline to the last value during the treatment phase (1.80 g/dl vs 0.19 g/dl) and after 12 weeks of treatment (2.66 g/dl vs 0.69 g/dl). A significantly lower percentage of patients in the darbepoetin alfa group received red blood cell transfusions than in the placebo group (P < 0.001). The efficacy of darbepoetin alfa was consistent for patients with lymphoma or myeloma. Improvements in quality of life were also observed with darbepoetin alfa. The overall safety profile of darbepoetin alfa was consistent with that expected for this patient population. Darbepoetin alfa significantly increased haemoglobin and reduced red blood cell transfusions in patients with lymphoproliferative malignancies receiving chemotherapy.

Quality of life measurement in patients with transfusion-dependent myelodysplastic syndromes

The myelodysplastic syndromes (MDS) are clonal disorders characterized by dysplasia in at least two myeloid cell lines. Fatigue is one of the most significant symptoms. MDS patients are treated with blood transfusions to improve their health-related quality of life (HRQoL). A cross-sectional pilot study was performed for psychometric evaluation of three internationally established HRQoL measures in MDS patients, and for investigation of the association between the severity of chronic anaemia and HRQoL. Fifty consecutive MDS patients completed the Short Form 36, the Multidimensional Fatigue Inventory and the EuroQoL-5D Visual Analogue Scale. Hb level was measured during the same visit. Psychometric analysis focused on feasibility, construct validity and reliability. The questionnaires showed a high feasibility, reliability and validity. MDS patients had worse HRQoL scores than the age- and sex-matched general population. We found a positive correlation between haemoglobin (Hb) level and HRQoL. This study provides insights into the suitability of established HRQoL measures for the evaluation of interventions in MDS patients. Hb value and HRQoL are complementary variables for evaluation of the severity of chronic anaemia in patients with MDS.

Stroma-supported progenitor production as a prognostic tool for graft failure following autologous stem cell transplantation

To analyse the involvement of a possible numerical or qualitative stem cell defect in the development of sustained graft failure after autologous transplantation, we have determined the graft content of CD34+ nucleated cells, colony-forming cells and cobblestone area-forming cell subsets, as well as transplant ability to produce progenitors using the long-term culture colony-forming cell (LTC-CFC) assay. We evaluated material from the graft reference ampoules of 13 graft failure patients after bone marrow transplantation (BMT), four graft failure patients and four isolated thrombocytopenia patients after peripheral blood stem cell transplantation (PBSCT). We compared these data with those from six successfully engrafted BMT patients and 20 engrafted PBSCT patients respectively. In the BMT setting, the LTC-CFC 6-week assay represented a highly significant graft failure predictor. In the PBSCT setting, the total number of 2-week and 6-week LTC-CFCs transplanted per kg bodyweight (BW) showed the highest significant difference between the engrafted and the graft failure patients, as well as between the engrafted patients and the patients suffering from isolated thrombocytopenia after transplantation. These data show that the ability of a graft to generate progenitors in vitro rather than the number of primitive progenitors transplanted can have prognostic value for post-transplant haematological reconstitution.

Diagnosis and treatment of portal vein thrombosis following splenectomy

BACKGROUND

Portal vein thrombosis is a rare but potentially fatal complication of splenectomy. The aim of this study was to assess the incidence, risk factors, treatment and outcome of portal vein thrombosis after splenectomy in a large series of patients.

METHODS

All patients who had undergone a splenectomy in the University Hospital, Rotterdam, between 1984 and 1997 were reviewed retrospectively. Splenectomy that was followed by symptomatic portal vein thrombosis was selected for analysis. Risk factors for portal vein thrombosis were sought.

RESULTS

Of 563 splenectomies, nine (2 per cent) were complicated by symptomatic portal vein thrombosis. All these patients had either fever or abdominal pain. Two of 16 patients with a myeloproliferative disorder developed portal vein thrombosis after splenectomy (P = 0.03), and four of 49 patients with haemolytic anaemia (P = 0.005). Treatment within 10 days after splenectomy was successful in all patients, while delayed treatment was ineffective.

CONCLUSION

Portal vein thrombosis should be suspected in a patient with fever or abdominal pain after splenectomy. Patients with a myeloproliferative disorder or haemolytic anaemia are at higher risk; they might benefit from early detection and could have routine Doppler ultrasonography after splenectomy.

Interleukin-6 and interleukin-1 enhancement of GM-CSF-dependent proliferation of haematopoietic progenitor cells in myelodysplastic syndromes

Interleukin-1 (Il-1) and Interleukin-6 (Il-6) have been reported to enhance the growth factor dependent colony formation of normal primitive haematopoietic progenitor cells as well as of leukaemic blast-cell progenitors. We investigated the effects of Il-1 beta and Il-6 in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF) on the in vitro colony formation of myeloid progenitors from 23 patients with a myelodysplastic syndrome (MDS). Neither Il-1 beta nor Il-6 were found to have colony stimulating activity on their own. In normal bone marrow cultures, either stimulated with optimal or suboptimal doses of GM-CSF, no enhancing or antagonistic effect of Il-6 or Il-1 beta was detected. In a majority of the MDS cases, however, an enhancing effect of Il-6 and Il-1 beta in combination with GM-CSF was observed (20/23 and 10/21 cases respectively). In three cases of the Il-6 and GM-CSF combination an antagonistic effect was observed as well as in four cases of the Il-1 beta and GM-CSF combination. A delayed addition of Il-6 to the cultures did not result in an abrogation of the effect, indicating that Il-6 is not required immediately at the initiation of the culture. These results indicate that costimulation with Il-6 or Il-1 beta is able to augment the GM-CSF activity on MDS myeloid progenitor cells.

The combined effects of Il-3, GM-CSF and G-CSF on the in vitro growth of myelodysplastic myeloid progenitor cells

The decreased or absent in vitro colony formation in response to single recombinant haematopoietic growth factors has been reported previously. Here we report on the effects of the combination of interleukin 3 (Il-3), granulocyte-macrophage colony-stimulating factor (GM-CSF) and granulocyte-CSF (G-CSF) and the effect of the conditioned medium of the giant tumour cell line (GCT-CM) on the proliferation of myelodysplastic (MDS) marrow myeloid progenitor cells and normal bone marrow (NBM) controls. Colony growth was most effectively sustained by GCT-CM and G-CSF in normal bone marrow (NBM) cultures. GM-CSF and Il-3 were less effective in inducing myeloid granulocytic colony growth, whereas the effects of Il-3 and GM-CSF were found to be approximately additive. The number of NBM granulocytic colonies induced by G-CSF and GCT-CM stimulation were comparable, whereas this granulocyte colony stimulating activity could be neutralized by anti-G-CSF antibodies. In addition GCT-CM was found to contain burst promoting activity, which could be neutralized by anti-Il-3 antibodies. Il-3 did not enhance the G-CSF activity in NBM cultures. No additive effect of stimulation with the combination of Il-3 and GM-CSF was observed in MDS marrow cultures, suggesting that these growth factors act on an identical progenitor cell population in MDS. G-CSF stimulated the growth of significantly lower colony numbers than GCT-CM, in contrast to NBM cultures. The decreased granulocytic colony formation of MDS marrow cells could clearly be enhanced by co-stimulation with Il-3. These results suggest that MDS myeloid progenitor cells require the exposure to both a pluripotent colony stimulating factor, like Il-3, and a lineage specific factor, like G-CSF, for optimal proliferation.