Background Managing thrombocytopenia with a prophylactic strategy was previously recommended for patients with impaired bone marrow function, hematological malignancies, and recipients of HCT when platelet counts declined to under 10,000/uL. However, the updated 2018 ASCO guidelines now suggest a place for a therapeutic i.e., after a bleeding event rather than a prophylactic platelet transfusion strategy for patients with hematologic malignancies undergoing autologous HCT. Studies show a lack of significant difference between trial groups in hemostatic outcomes, such as the number of WHO grade 2-4 bleeds, and number of days with bleeding events. Platelet transfusions increase risks of infectious and non-infectious complications as well as inducing a platelet refractory state. Our Transfusion Free Medicine Program has now performed over 200 autologous hematopoietic stem cell transplants (HCT) in Jehovah's Witnesses who due to religious convictions, do not accept red cell or platelet transfusions. Vitamin K is a fat-soluble vitamin that is required for normal blood clotting. Autologous HCT patients are at risk for vitamin K deficiency from multiple reasons including malnutrition, frequent use of antibiotics, chemotherapy induced gastrointestinal toxicity leading to malabsorption and colitis. The prothrombin test lacks the sensitivity and specificity to detect mild deficiency. A mild vitamin K deficiency may be underdiagnosed in our transplant patients adding to bleeding risk. With the effective use of antifibrinolytic agents and Vitamin K as an alternative to platelet transfusions we believe this may enhance hemostasis and prove a valuable adjunct to a therapeutic approach. Methods Patients in our study were those who were of the Jehovah's Witness faith undergoing autologous HCT for Multiple Myeloma and Lymphoma. Patients received aminocaproic acid as an alternative to platelet transfusion to enhance hemostasis at a dose of 1 g every 4 hours or prophylactically for platelet counts less than 30,000 /uL. Titration to 4 g every 4 hours intravenously was required for platelet counts less than 10,000/ul or clinical bleeding. Vitamin K 10 mg orally or subcutaneous was also started at this time. Results Table 1 illustrates the low number of bleeding events especially grade 3 or 4 that occurred. There were no Grade 3 or 4 bleeding events in patients with platelet counts above 5000/uL. No patient had residual long term effects nor was there an increase in thromboembolic events. Conclusions These data add to the body of literature supporting a therapeutic platelet transfusion strategy in an experienced center for autologous HCT patients and challenges the prophylactic platelet count of 10,000 /uL suggesting instead 5000/uL. The safety and efficacy of antifibrinolytic agents and Vitamin K as an alternative to platelet transfusions to enhance hemostasis in autologous stem cell transplant patients may prove beneficial not only in JW patients but also in those transplant centers wishing to offer a therapeutic platelet transfusion approach and as a strategy to manage platelet refractoriness. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Aminocaproic Acid is an antifibrinolytic agent approved for treatment of bleeding in surgical patients and hematological bleeding disorders. Vitamin K is approved for use in reversal of anticoagulation from Warfarin, vitamin K deficiency without liver disease and in the newborn.
Cardiac surgery has a risk for extensive blood loss which poses a particular challenge in individuals refusing blood transfusions. Additionally, preoperative anemia with a hemoglobin (Hb) below 13 g/dL in men and 12 g/dL in women is associated with increased short and long-term complications and mortality and increases the need for blood transfusion support. The current guidelines for perioperative anemia management recommend optimizing hemoglobin levels prior to surgery and utilizing blood conservation techniques during the procedure. At present red blood cell (RBC) transfusions during cardiac surgery are usually recommended when Hb levels are below 7-8 g/dL a restrictive transfusion strategy to reduce complications. However, the use of any RBC transfusions is associated with worse outcomes in cardiac surgery compared with those who do not receive transfusions. We have found that JW seek out quality health care and accept the vast majority of medical treatments once they are educated. The Transfusion Free Medicine Coordinator's role in the Anemia Clinic is to endorse clinical strategies for managing hemorrhage and anemia without blood transfusion. They educate and counsel the patients so they can decide as to what blood fractions and cell salvage techniques they will accept. We have found that some Health Care Providers are unaware that ESAs also contain albumin so JW patients may be given this product without that knowledge. The vast majority of patients will accept the use of ESAs but find the cost prohibitive. Jehovah's Witness patients have provided a natural case study for examining how well adjuvant therapies can improve preoperative anemia without transfusions and continue with good outcomes. Hb optimization is achieved through the use of intravenous iron and, if needed, erythropoiesis stimulating agents (ESAs). In Table 1 we highlight our single center data in which all cardiovascular surgeries were performed by a surgeon experienced in blood-conservation strategies. Our thirty-day re-admission rates for all patients was zero percent, compared to state-specific data, which estimates about an 11.7% rate of re-admission. The data illustrate the need to have a target Hb 13 or above to allow for the decline that may occur during the hospital stay. Of note no thromboembolic events have occurred with the use of an ESA in this group. Although ESAs are approved to optimize Hb in orthopedic surgery, they are not covered for cardiac surgery which has presented a significant challenge to patients who can not safely proceed to surgery until a target Hb between 13 to 15 g/dL is achieved. These data highlight the utility and safety associated with the use of ESAs for patients who do not accept blood products at an experienced Center for Transfusion-Free Medicine, such as ours. At this time, since insurance companies do not cover the cost of ESAs for patients needing life-saving cardiovascular operations, cost is a prohibitive barrier for patients. Unfortunately, it is not uncommon for patients to have to borrow money from others or set up payment plans. We hope that analyses like ours will help drive changes in reimbursement policies, particularly for patients who based on religious convictions, cannot receive blood products, and thus for whom pre-operative hemoglobin optimization is of utmost importance. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Erythropoiesis-stimulating agent (ESA) are indicated for the treatment of anemia due to Chronic Kidney Disease in patients on dialysis and not on dialysis, Zidovudine in patients with HIV-infection, anemia due to myelosuppressive chemotherapy and reduction of allogeneic RBC transfusions in patients undergoing elective, noncardiac, nonvascular surgery
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.