Randomized study of prophylactic platelet transfusion threshold during induction therapy for adult acute leukemia: 10,000/microL versus 20,000/microL.

PURPOSE We designed and conducted a randomized single-institution trial comparing two common prophylactic platelet transfusion thresholds in patients undergoing induction therapy for acute leukemia. PATIENTS AND METHODS Seventy-eight patients undergoing induction therapy for acute leukemia were randomized to receive prophylactic apheresis platelet concentrates when the platelet count was either < or = 10,000/microL or < or = 20,000/microL. RESULTS There was no significant difference in the total number of bleeding episodes per patient with a median of four in the < or = 10,000/microL arm and two in the < or = 20,000/microL arm (25th to 75th percentiles of 2, 7 and 1, 5, respectively; P = .12). Patients randomized to the < or = 10,000/microL arm received more platelet transfusions for bleeding [one (0, 2) v zero (0, 0); P = .0003]. In contrast, patients on the < or = 20,000/microL arm received more platelet transfusions for prophylactic indications [10 (5, 14) v six (3, 8); P = 0.001], as would be expected, but less for bleeding. Nevertheless, the total number of platelet transfusions given to patients on the < or = 20,000/microL arm was higher and nearly significant [11 (6, 15) v seven (5, 11); P = .07]. There were no statistically significant differences between the groups with regard to RBC transfusion requirements, febrile days, days hospitalized, days thrombocytopenic, need for HLA-matched platelets, remission rate, or death during induction chemotherapy. No patient in either group died from hemorrhage or underwent major surgery for bleeding complications. CONCLUSION Giving prophylactic platelets at a threshold of < or = 10,000/microL compared with < or = 20,000/microL can decrease the total utilization of platelets with only a small adverse effect on bleeding, and no statistically significant effect on morbidity.

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High Incidence of Alloimmunization to Platelets and Platelet Transfusion Refractoriness during Induction Therapy in Patients Diagnosed with Acute Myeloid Leukemia

Blood ◽

10.1182/blood.v126.23.3484.3484 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3484-3484

Author(s):

Lilach Bonstein ◽

Roy Lauterbach ◽

Nuhad Haddad

Keyword(s):

Acute Myeloid Leukemia ◽

Induction Therapy ◽

Myeloid Leukemia ◽

Platelet Transfusion ◽

Newly Diagnosed ◽

Hla Antibodies ◽

Antibody Screening ◽

Transfusion Requirements ◽

Acute Myeloid ◽

Platelet Transfusions

Abstract Introduction: Patients with acute myeloid leukemia (AML) are treated with intensive chemotherapeutic protocols. They are known to suffer from protracted pancytopenia and need prolonged transfusion support. Despite the administration of leukocyte-reduced and irradiated blood products, long-term transfusion dependency predisposes these patients to alloimmunization to both leukocyte (HLA) and platelet (HPA) antigens, leading to immune platelet transfusion refractoriness, which is a major risk factor for bleeding-associated morbidity and mortality, to longer hospitalizations and higher inpatient hospital costs. The published incidence of immune platelet refractoriness in patients with hematologic malignancies ranges between 7% and 34%. The Rambam Health Care Campus is the only tertiary care medical center in Northern Israel providing services to over 2 million citizens. This population is highly heterogeneousin terms of ethnic and religious background and has a relatively high birth rate (3.2 versus 1.75 in other developed countries). The majority of AML patients in the region are treated at the Rambam Department of Hematology. To the best of our knowledge, the incidence of alloimmunization to platelet antigens and immune platelet refractoriness in this population has never been studied. The aims of the current study were: to estimate the incidence of immune platelet transfusion refractoriness among AML patients in Northern Israel, to define the onset of alloimmunization during the treatment course and to evaluate the efficacy of antibody screening by platelet immunofluorescent test (PIFT) as a follow-up tool to predict the risk for alloimmunization and immune platelet transfusion refractoriness in these patients. Methods: Newly diagnosed AML patients were screened every two weeks for two months since diagnosis and throughout induction therapy for the presence of anti-HPA and anti-HLA antibodies using flow cytometry (PIFT assay). Antibodies were identified by the monoclonal-specific immobilization of platelet antigens (MAIPA) assay. Clinical parameters of patients were consecutively registered. Patients received platelet transfusions according to the institutional transfusion policy, including continuous platelet increment monitoring. Blood counts and platelet transfusion requirements were followed weekly; platelet refractoriness was determined when no increment (defined as an increase <5x109 platelets/L after a single transfusion of 3x1011 platelets) was documented following two consecutive platelet transfusions. Results: One hundred newly diagnosed AML patients (56 males and 44 females; age range 25-60 years) of various ethnic origins were included in the analysis. Platelet refractoriness was revealed in 49 (49%) patients (20 males and 29 females). Forty four (44%) patients developed anti-HLA and/or anti-HPA antibodies, 32/44 (73%) were females, 27 of them with more than two children. Immune platelet refractoriness was revealed in 34/49 (69%) refractory patients (8 males and 26 females); 13/34 (38%) had anti-HPA with (11) or without (2) anti-HLA antibodies and 21/34 (62%) had only anti-HLA antibodies. The average period from the beginning of treatment to antibody appearance was 26 days. The PIFT was found to be a sensitive, specific and efficient method for screening and detection of all anti-platelet antibodies, while MAIPA was found to be the preferred method for anti-platelet antibody identification. Conclusions: Women with more than two children were found to have a significantly higher risk to develop alloantibodies and transfusion refractoriness. Our findings demonstrating a higher incidence of immune platelet refractoriness compared to that reported in the literature may be attributed to the increased prevalence of multiparous women inhabiting our region. Routine antibody screening by PIFT appears to be an efficient tool for early detection of alloimmunized patients. Disclosures No relevant conflicts of interest to declare.

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A Pilot Study to Evaluate the Feasibility of Anti-Fibrinolytic Agents in Reducing Hemorrhagic Complications in Pediatric Patients with Thrombocytopenia

Blood ◽

10.1182/blood-2020-134794 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 3-3

Author(s):

Meghan McCormick ◽

Meghan Delaney ◽

Cheryl A Hillery ◽

Ram Kalpatthi ◽

Darrell J Triulzi

Keyword(s):

Platelet Count ◽

Tranexamic Acid ◽

Platelet Transfusion ◽

Pediatric Patients ◽

Bleeding Complications ◽

Study Medication ◽

Fibrinolytic Agents ◽

Risk Of Bleeding ◽

Transfusion Requirements ◽

Platelet Transfusions

Background: The risk of bleeding remains high in thrombocytopenic pediatric hematology-oncology patients despite the use of prophylactic platelet transfusions. In one study, WHO grade 2 or higher bleeding occurred in >80% of pediatric subjects receiving hematopoietic stem cell transplantation or chemotherapy despite a platelet transfusion threshold of 10,000/µl. The risk of bleeding is not decreased with higher transfusion thresholds or increased platelet doses. Bleeding episodes are associated with increased mortality rates, greater utilization of resources and increased transfusion requirements. We examined the use of anti-fibrinolytic agents in decreasing bleeding events and platelet transfusions. Methods: We conducted a randomized double-blinded Phase 2 trial of tranexamic acid versus placebo in inpatient pediatric patients undergoing chemotherapy or HSCT expected to have prolonged thrombocytopenia. All patients admitted to the Oncology or HSCT services were screened for eligibility. Patients consenting for enrollment received either tranexamic acid 10m/kg/dose or normal saline every 8 hours while the platelet count as <30,000/ul until discharge or spontaneous platelet recovery (maximum 30 days). We conducted daily hemostatic assessments using the WHO bleeding scale and monitored adverse events and platelet transfusion requirements. Follow-up assessments took place at 7 and 30 days following completion of study medication. Primary aims were to assess safety and feasibility of tranexamic acid in children with hypoproliferative thrombocytopenia. Results: We screened 697 admissions over 11 months, 31 patients were eligible for enrollment. Enrollment was suspended in March 2020 for COVID reasons though screening continued through July 2020. An additional 10 eligible patients were identified in this period. The most common reasons for ineligibility included recent asparaginase administration, predicted inpatient stay <5 days and age ≤ 2 or ≥ 18 years. Eleven patients enrolled and completed all study procedures. There were no missed doses of medication, 88.4% of doses were administered within one hour of prescribed time. Patients remained on study for a mean of 11.1 days. Five patients each met criteria for spontaneous platelet count recovery or discharge, 1 patient received the study medication for 30 days. Bleeding (all grades) occurred on 29.5% of days. Grade 2 or higher bleeding occurred on 4.9% of days and was experienced by 27.3% of patients. The most common sites of bleeding were oral/nasal and cutaneous. Subjects received a median of 2 platelet transfusions per patient. There were no thromboembolic events or serious adverse events. Conclusion: Tranexamic acid is well tolerated can be safely administered to pediatric oncology patients as an adjunct to therapy. We are planning a multi-center randomized controlled trial to assess the efficacy of tranexamic acid in reducing bleeding complications in this population. Disclosures Triulzi: Fresenius Kabi: Consultancy; Cerus Corp: Research Funding. OffLabel Disclosure: Tranexamic Acid - This medication is being studied as an adjuvant to therapy to prevent bleeding complications and reduce platelet transfusions in pediatric patients with hypoproliferative thrombocytopenia.

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A Restrictive Platelet Transfusion Policy Allowing Long-Term Support of Outpatients With Severe Aplastic Anemia

Blood ◽

10.1182/blood.v93.9.3124 ◽

1999 ◽

Vol 93 (9) ◽

pp. 3124-3126 ◽

Cited By ~ 68

Author(s):

Markus Sagmeister ◽

Lic Oec ◽

Jürg Gmür

Keyword(s):

Aplastic Anemia ◽

Platelet Transfusion ◽

Severe Aplastic Anemia ◽

Bleeding Complications ◽

Outpatient Basis ◽

Platelet Counts ◽

The Mean ◽

Restrictive Policy ◽

Platelet Transfusions

Abstract The threshold for prophylactic platelet transfusions in patients with hypoplastic thrombopenia generally recommended in the standard literature is 20,000 platelets/μL. A more restrictive transfusion policy may be indicated in patients with chronic severe aplastic anemia (SAA) in need of long-term platelet support. We evaluated the feasibility and safety of a policy with low thresholds for prophylactic transfusions (≤5,000 platelets/μL in stable patients; 6,000 to 10,000 platelets/μL in cases with fever and/or hemorrhagic signs) combined with progressive lengthening of transfusion intervals (up to at least 7 days irrespective of the interim course of platelet counts). The study was based on a retrospective analysis of a total of 18,706 patient days with platelet counts ≤10,000/μL in patients with chronic SAA treated (for more than 3 months) on an outpatient basis. Altogether, 1,135 platelet transfusions were given, 88% at counts ≤10,000/μL and 57% at counts ≤5,000/μL. The mean transfusion interval was 10 days. During the period of observation, three major nonlethal bleeding complications occurred, which could be well controlled. We conclude that the restrictive policy with low transfusion thresholds and prolonged transfusion intervals proved feasible and safe in chronic SAA patients.

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Delayed alloimmunization using random single donor platelet transfusions: a prospective study in thrombocytopenic patients with acute leukemia

Blood ◽

10.1182/blood.v62.2.473.473 ◽

1983 ◽

Vol 62 (2) ◽

pp. 473-479 ◽

Cited By ~ 95

Author(s):

J Gmur ◽

A von Felten ◽

B Osterwalder ◽

H Honegger ◽

A Hormann ◽

...

Keyword(s):

Acute Leukemia ◽

Prospective Study ◽

Randomized Study ◽

Platelet Concentrates ◽

Single Donor ◽

Time Period ◽

A Prospective Study ◽

Platelet Transfusions

Abstract A randomized study was performed in 54 thrombocytopenic patients with acute leukemia. Alloimmunization of recipients of random multiple-donor platelet concentrates (MD group) was compared to that of patients receiving random single-donor platelets (SD group). In the SD patients, formation of alloantibodies (mostly anti-HLA) occurred less frequently (p less than 0.002), after a longer time period (p less than 0.002), and after a higher number of transfusions (p less than 0.005) as compared to MD patients. SD patients also became refractory to random platelets less frequently (p less than 0.005), after a longer time period, and after a higher number of transfusions (p less than 0.02). In SD patients, the increments after the first and the last transfusion were in the same range, whereas in MD patients, the 1-hr (p less than 0.001) and the 24-hr (p less than 0.025) increments decreased from the first to the last transfusion. Thus, the use of random SD platelet transfusions postponed alloimmunization.

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Comparing the Efficacy and Safety of Induction Therapies for the Treatment of Patients with Proliferative Lupus Nephritis in South Africa

International Journal of Nephrology ◽

10.1155/2020/2412396 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7

Author(s):

Phelisa Sogayise ◽

Udeme Ekrikpo ◽

Ayanda Gcelu ◽

Bianca Davidson ◽

Nicola Wearne ◽

...

Keyword(s):

South Africa ◽

Lupus Nephritis ◽

Induction Therapy ◽

Randomized Study ◽

Induction Treatment ◽

Limited Data ◽

Proliferative Lupus Nephritis ◽

Significant Difference ◽

Kidney Replacement Therapy

Background. Lupus nephritis (LN) can be complicated with requirement for kidney replacement therapy and death. Efficacy of induction therapies using mycophenolate mofetil (MMF) or intravenous cyclophosphamide (IVCYC) has been reported from studies, but there is limited data in Africans comparing both treatments in patients with proliferative LN. Methods. This was a retrospective study of patients with biopsy-proven proliferative LN diagnosed and treated with either MMF or IVCYC in a single centre in Cape Town, South Africa, over a 5-year period. The primary outcome was attaining complete remission after completion of induction therapy. Results. Of the 84 patients included, mean age was 29.6 ± 10.4 years and there was a female preponderance (88.1%). At baseline, there were significant differences in estimated glomerular filtration rate (eGFR) and presence of glomerular crescents between both groups ( p ≤ 0.05 ). After completion of induction therapy, there was no significant difference in remission status (76.0% versus 87.5%; p = 0.33 ) or relapse status (8.1% versus 10.3%; p = 0.22 ) for the IVCYC and MMF groups, respectively. Mortality rate for the IVCYC group was 5.5 per 10,000 person-days of follow-up compared to 1.5 per 10,000 person-days of follow-up for the MMF group ( p = 0.11 ), and there was no significant difference in infection-related adverse events between both groups. Estimated GFR at baseline was the only predictor of death (OR: 1.0 [0.9–1.0]; p = 0.001 ). Conclusion. This study shows similar outcomes following induction treatment with MMF or IVCYC in patients with biopsy-proven proliferative LN in South Africa. However, a prospective and randomized study is needed to adequately assess these outcomes.

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Transfusion Practice Following Intracranial Hemorrhage in Acute Leukemia: An Institutional Review

Blood ◽

10.1182/blood-2018-99-112718 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4740-4740

Author(s):

Shannon Nixon ◽

Dawn Maze ◽

Eshetu G Atenafu ◽

Danielle Brandys ◽

Cindy Susan Murray ◽

...

Keyword(s):

Platelet Count ◽

Retrospective Study ◽

Acute Leukemia ◽

Intracranial Hemorrhage ◽

Platelet Transfusion ◽

Transfusion Practice ◽

Rank Test ◽

Transfusion Threshold ◽

Platelet Counts ◽

Platelet Transfusions

Abstract Background: Intracranial hemorrhage (ICH) is a common complication in acute leukemia that is associated with significant morbidity and mortality. While evidence supports prophylactic platelet transfusions at a threshold < 10 x 109/L to reduce the risk of bleeding in acute leukemia, there is little data to guide platelet transfusion practice in patients following ICH. The objectives of this study were to characterize the clinical features and outcomes of acute leukemia patients with ICH and to understand current platelet transfusion practice following ICH. Methods: This was a retrospective study conducted at a large, quaternary, academic cancer centre. We included all adult patients with a diagnosis of acute leukemia who had a documented ICH at our centre between January 1, 2009 and December 31, 2016. We assessed demographics, medications, infection and bleeding history in the week preceding ICH, characteristics of ICH including site of bleed, acute management, transfusion practice in the first 90 days, and clinical outcomes. Radiologic scans were re-assessed by neuroradiology to determine if the ICH was stable or if new or progressive bleeding had developed. Transfusion practice following the ICH was compared between the two groups with longitudinal data analysis using platelet counts as outcome. Kaplan-Meier product limit method was used to estimate overall survival (OS) rates as well as to obtain median survival; log-rank test was used to compare OS among those without new or progressive ICH vs. those with progression. Results: During the study period, of 2576 patients diagnosed with acute leukemia, 101 suffered from ICH and were included in the study. Most patients (94) had AML, of which 9 had APL, 6 had ALL, and 1 had MPAL. At the time of ICH, 61 patients were newly diagnosed or receiving induction chemotherapy, 33 had relapsed disease and 7 were in complete remission. Spontaneous ICH occurred in 76 patients. Within the week preceding ICH, 7 patients were on medications known to increase bleeding risk and 39 were on tranexamic acid. Sixty-four patients had clinical evidence of bleeding elsewhere and 22 had evidence of infection. On the day of ICH, the median platelet count was 16 x 109/L (range 0- 433 x109/L). Thirty-one patients had a platelet count < 10 x 109/L and 10 of these patients received a platelet transfusion prior to the bleed. Seventy patients had a platelet count ≥10 x109/L and 17 of these received a platelet transfusion prior to the bleed. Six patients (6%) exhibited evidence of platelet transfusion refractoriness. In the 90 days following ICH, 21% of platelet transfusions were given for a platelet count < 10 x 109/L, 55% were given with a platelet count between 10-29 x109/L, and 24% were given with a platelet count ≥ 30 x 109/L. New or progressive ICH occurred in 28 patients. The median platelet transfusion threshold was 19 x 109/L (range 0-114 x 109/L) for those without new or progressive ICH and 21 x 109/L (range 0-93 x 109/L) for those with progression (p=0.04; Figure 1). Of the 101 study patients, 79 have died. Median OS was 5.6 months for those without new or progressive ICH and 2.9 months for those with progression (p=0.002) (Figure 2). Cause of death was attributed to non-ICH causes in the majority of patients 65/79 (82%). Conclusions: In this retrospective study, we evaluated the outcomes of 101 patients with acute leukemia and ICH. At the time of the bleed, the majority of patients had active disease and more than two thirds had platelet counts of 10 x 109/L or higher. During 90 days of follow-up, nearly one third of patients developed new or progressive ICH. Platelet transfusion practice was variable and the median threshold was, in fact, higher in those who subsequently developed new or progressive bleeding. The reasons for this were unclear from our chart review, but we hypothesize that these patients may have had additional risk factors, e.g. fever, infection. The outcomes of patients with acute leukemia and ICH are poor. Factors other than platelet transfusion threshold likely contribute to secondary ICH events and the overall poor prognosis. Disclosures Maze: Novartis: Consultancy, Honoraria.

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Severe Thrombocytopenia Does Not Increase Bleeding Complications in Patients Undergoing Bronchoscopy

Blood ◽

10.1182/blood.v124.21.4293.4293 ◽

2014 ◽

Vol 124 (21) ◽

pp. 4293-4293

Author(s):

Lakshminarayanan Nandagopal ◽

Muthu Veeraputhiran ◽

Tania Jain ◽

Ayman Soubani ◽

Charles A. Schiffer

Keyword(s):

Platelet Count ◽

Renal Dysfunction ◽

Platelet Transfusion ◽

Conflicts Of Interest ◽

Bleeding Complications ◽

British Thoracic Society ◽

Severe Thrombocytopenia ◽

Platelet Counts ◽

Number Of Patients ◽

Platelet Transfusions

Abstract Introduction Prophylactic platelet transfusions are often performed prior to bronchoscopy or broncho-alveolar lavage (BAL) to prevent bleeding in thrombocytopenic patients. There is a paucity of data to validate this approach, with a platelet transfusion threshold of <50,000/mm3 largely based on expert opinion. We conducted a retrospective study on the incidence of bleeding complications in thrombocytopenic patients undergoing bronchoscopy. Methods We identified 150 consecutive patients with platelet counts <100,000/mm3 who underwent bronchoscopy and/or BAL from January 2009 to May 2014 at our institution. Bronchoscopies performed in patients with frank hemoptysis and trans-bronchial lung biopsy procedures were excluded. Patient characteristics, underlying diagnosis, platelet count prior to bronchoscopy, administration of platelet transfusions and bronchoscopy details were recorded. Factors affecting bleeding risk including presence of renal dysfunction (defined as BUN >30 and/or Cr>2.0) and coagulation studies (PT, PTT, INR) were identified. The British Thoracic Society guidelines1 were used to categorize bleeding as a result of bronchoscopy. Data were analyzed using descriptive statistics. Results The median age was 59 years (range 27-90), with two-thirds of patients (63%) being male. One hundred and seventeen (78%) patients had underlying malignancy and 55 (37%) had thrombocytopenia related to malignancy. Fellows and residents under the supervision of a bronchoscopy certified attending performed all but 4 of the bronchoscopies. Infection (40%) was the primary indication for bronchoscopy with BAL performed in 127 (85%) patients. Fifty-eight of 89 (65%) patients with baseline platelet counts <50,000/mm3 received prophylactic transfusions compared to 8% of those with platelet counts >50,000/mm3. The platelet count did not rise to >50,000//mm3 in many transfused patients. Seventy patients (47%) had counts <50,000/mm3 and eighty patients (53%) had counts >50,000/mm3 at the time of bronchoscopy. 49% were receiving immunosuppressive medications, 45% had renal dysfunction and 8% had INR >1.5. Bloody lavage that resolved spontaneously without continuous suctioning (Grade 0) was observed in 9 (6%) patients. Bleeding that required continuous suctioning but then resolved spontaneously (Grade 1) was noted in 1 patient with a platelet count of 61,000/mm3. Of 10 total bleeding events, 7 occurred in patients who were intubated. Two additional patients with platelet counts of 30,000/mm3 and 53,000/mm3 had diffuse alveolar hemorrhage, which was present before bronchoscopy. “Old” blood and blood clots were observed in 6 patients. Discussion The low incidence of bleeding complications from bronchoscopy +/- BAL even in patients with platelet counts <30,000/mm3 (3 episodes in 31 patients, all grade 0) demonstrates that bronchoscopy can be safely done in severely thrombocytopenic patients. Adopting a lower threshold for prophylactic transfusions could save a considerable number of platelet units and translate into significant cost savings and decreased risk of transfusion-related complications. Table 1 Platelet count, transfusion history and bleeding complications during bronchoscopy Platelet count at the time of bronchoscopy Number (n) and percentage (%) of patients who underwent bronchoscopy Number of patients who received prior platelet transfusion Bleeding during bronchoscopy n % 0-15,000/mm3 9 6% (9/150) 5 Grade 0=1 pt 16-29 22 15% 16 Grade 0=2 pts 30-39 17 11% 9 Grade 0=1 pt 40-49 22 15% 9 Grade 0=3 pts 50-75 44 29% 14 Grade 1=1 pt 76-100 36 24% 10 Grade 0=2 pts Total 150 63 Grade 0=9 pts, Grade 1=1 pt. 1.Du Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013:68 Suppl 1:i1-i44 Disclosures No relevant conflicts of interest to declare.

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Interim Analysis of a Prospective Randomised Study Comparing a Therapeutic Platelet Transfusion Strategy with the Prophylactic Platelet Transfusion Standard in Patients after Autologous Peripheral Stem Cell Transplantation (ASCT).

Blood ◽

10.1182/blood.v108.11.577.577 ◽

2006 ◽

Vol 108 (11) ◽

pp. 577-577 ◽

Cited By ~ 3

Author(s):

Kerstin Schaefer-Eckart ◽

Knut Wendelin ◽

Martin Wilhelm ◽

U. Mahlknecht ◽

R. Conradi ◽

...

Keyword(s):

Stem Cell ◽

Platelet Count ◽

Stem Cell Transplantation ◽

Interim Analysis ◽

Platelet Transfusion ◽

Transfusion Strategy ◽

Randomised Study ◽

Peripheral Stem Cell Transplantation ◽

Significant Difference ◽

Platelet Transfusions

Abstract We have previously shown, that a therapeutic platelet transfusion strategy is safe in patients after autologous peripheral stem cell transplantation(ASCT) and can reduce the number of platelet transfusions to about 50% compared with the prophylactic strategy (Wandt et al, BMT2006, 37, 387–392). To confirm these results, we started a randomised multicenter study in 2005 and present the results of the first planned interim analysis. In the prophylactic platelet transfusion arm (p) transfusions were given to patients if the morning platelet count was < 10/nl, while in the therapeutic transfusion arm (t) clinically stable patients (no sepsis or systemic inflammatory response syndrome II° or III° (SIRS), no invasive Aspergillosis or infection with Stenotrophomonas maltophilia) received platelet transfusions only in the case of clinically relevant bleeding. Apheresis platelets were recommended, but pooled platelet units were allowed as well. We now analysed the first 92 patients, 45 patients with a prophylactic and 47 patients with a therapeutic transfusion strategy. Both groups were well balanced according to age, gender, diagnosis and conditioning regimens. Median days of thrombocytopenia < 20/nl were 4 (0–14) in the prophylactic and 4 (0–20) in the therapeutic arm. The corresponding days regarding platelets below 10/nl were 1(p) (0–5) and 2(t) (0–14), respectively. The total number of days with thrombocytopenia <20/nl was 185 in the prophylactic arm and 239 in the therapeutic arm, resp. The number of days with a platelet count below 10/nl was 63 (p) vs. 110 (t). The number of days in hospital was 15 (p) (6–29) and 14 (t) (9–29), resp. Minor hemorrhages were observed in only 13 patients: 4 out of 45 patients in the prophylactic arm (8,9%) and 9 out of 47 patients in the therapeutic arm (19,2%). This difference was due to the protocol strategy and not significant. We observed no major clinically relevant bleedings. There was a significant difference in the number of transfused platelet units: 68 (p) vs 37 (t), (p=0,005). The median number of platelet units was 1(0–6) in the prophylactic arm and 0(0–5) in the therapeutic arm. More than 95% of the transfusions were single apheresis units. So the primary objective of the study, a reduction of platelet transfusions by 25% was reached, without significant difference in the number of major bleeding complications (secondary objective). 9 out of the 37 platelet transfusions (24%) in the therapeutic strategy arm were given because of sepsis or SIRS and in 4 out of the 37 (11%) transfusions there was no indication according to the protocol. There was a non-significant difference in the number of red blood cell transfusions: 59 (median 0, range 0–8) in the prophylactic arm versus 87 (median 2, range 0–12) in the therapeutic arm. With these first results of the randomised study we could confirm that a therapeutic platelet transfusion strategy is safe and can reduce the number of platelet transfusions by about 50%. The study will continue until 200 patients are included.

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A Restrictive Platelet Transfusion Policy Allowing Long-Term Support of Outpatients With Severe Aplastic Anemia

Blood ◽

10.1182/blood.v93.9.3124.409a35_3124_3126 ◽

1999 ◽

Vol 93 (9) ◽

pp. 3124-3126 ◽

Cited By ~ 1

Author(s):

Markus Sagmeister ◽

Lic Oec ◽

Jürg Gmür

Keyword(s):

Aplastic Anemia ◽

Platelet Transfusion ◽

Severe Aplastic Anemia ◽

Bleeding Complications ◽

Outpatient Basis ◽

Platelet Counts ◽

The Mean ◽

Restrictive Policy ◽

Platelet Transfusions

The threshold for prophylactic platelet transfusions in patients with hypoplastic thrombopenia generally recommended in the standard literature is 20,000 platelets/μL. A more restrictive transfusion policy may be indicated in patients with chronic severe aplastic anemia (SAA) in need of long-term platelet support. We evaluated the feasibility and safety of a policy with low thresholds for prophylactic transfusions (≤5,000 platelets/μL in stable patients; 6,000 to 10,000 platelets/μL in cases with fever and/or hemorrhagic signs) combined with progressive lengthening of transfusion intervals (up to at least 7 days irrespective of the interim course of platelet counts). The study was based on a retrospective analysis of a total of 18,706 patient days with platelet counts ≤10,000/μL in patients with chronic SAA treated (for more than 3 months) on an outpatient basis. Altogether, 1,135 platelet transfusions were given, 88% at counts ≤10,000/μL and 57% at counts ≤5,000/μL. The mean transfusion interval was 10 days. During the period of observation, three major nonlethal bleeding complications occurred, which could be well controlled. We conclude that the restrictive policy with low transfusion thresholds and prolonged transfusion intervals proved feasible and safe in chronic SAA patients.

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Percutaneous Renal Biopsy: Comparison of Blind and Real-time Ultrasound Guided Technique

Journal of Nepal Health Research Council ◽

10.3126/jnhrc.v16i1.19369 ◽

2018 ◽

Vol 16 (1) ◽

pp. 66-72 ◽

Cited By ~ 2

Author(s):

Anil Pokhrel ◽

Rajendra Kumar Agrawal ◽

Anil Baral ◽

Ajaya Rajbhandari ◽

Rajani Hada

Keyword(s):

Renal Biopsy ◽

Real Time ◽

Randomized Study ◽

Bleeding Complications ◽

Renal Diseases ◽

Ultrasound Guided ◽

Macroscopic Hematuria ◽

Percutaneous Renal Biopsy ◽

Significant Difference ◽

Perinephric Hematoma

Background: Percutaneous renal biopsy is performed for diagnosis and prediction of prognosis of renal diseases. Adequacy of tissue and clinically significant bleeding are the main issues of the procedure. We aimed to compare these issues in renal biopsy by blind and real time ultrasound guided technique.Methods: It was a cross sectional, randomized study conducted between June 2016 to December 2016. In blind technique, marking for biopsy was done by ultrasound. Two attempts were performed for all and more if tissue was inadequate. Patients kept in bed rest for 24 hours, observed for post procedure hematuria and ultrasound done at 6 hours and 24 hours to diagnose perinephric hematoma.Results: Total 75 biopsies (blind = 37 and Ultrasound -guided = 38) were evaluated. Blind and Ultrasound-guided technique had significant difference of number of attempt (mean±SD) 2.4±0.6 and 2.1±0.3 (p<0.01) respectively with no difference of number of glomeruli in light microscopy. Bleeding complications were macroscopic hematuria (11(30%)vs15(40%)) and perinephric hematoma ( 5(13.5%)vs3(7.9%)) in blind and Ultrasound-guided technique respectively with no significant difference. Those patients who developed perinephric hematoma was observed in all at 6 hours.Conclusions: Ultrasound-guided technique of percutaneous renal biopsy is superior with fewer attempts and equivalent in adequacy of tissue and bleeding complication than blind technique.

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