Red cell transfusions: Is less always best?

Mo, Allison; Stanworth, Simon; Shortt, Jake; Wood, Erica M.; McQuilten, Zoe

doi:10.1111/trf.16429

Cited by 4 publications

(3 citation statements)

References 58 publications

(139 reference statements)

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“…One criticism of previous transfusion trials is the lack of a "usual care treatment group" which renders results less relevant for patients; for example, Hb thresholds for restrictive versus liberal strategies are arbitrarily determined and applied to all participants, regardless of individual clinical characteristics, personal preferences or circumstances. 39,40 The n-of-1 study design in REDDS2 enables both treatment arms to be individualized for each participant. The results will not only better reflect realworld practices, but are also directly relevant to the patient.…”

Section: Discussionmentioning

confidence: 99%

Rethinking the transfusion pathway in myelodysplastic syndromes: Study protocol for a novel randomized feasibility n‐of‐1 trial of weekly‐interval red cell transfusion in myelodysplastic syndromes

Mo,

Wood,

Shortt

et al. 2024

Transfusion

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BackgroundAnemia in myelodysplastic syndromes (MDS) is associated with poorer health‐related quality of life (HRQoL) and physical function, and is frequently treated with transfusions. The current common practice of transfusing multiple red blood cells (RBC) units every 2–4 weeks may result in peaks/troughs in hemoglobin (Hb) level, yet maintaining a stable Hb may better improve HRQoL. We describe a study protocol aiming to investigate the feasibility of weekly low‐dose RBC transfusion in MDS patients, including assessing HRQoL and physical function outcomes.Study Design and MethodsIn this n‐of‐1 pilot study, patients receive two treatment arms, with randomly allocated treatment sequence: arm A (patient's usual transfusion schedule) and arm B (weekly transfusion, individualized per patient). To facilitate timely delivery of weekly transfusion, extended‐matched RBCs are provided, with transfusion based upon the previous week's Hb/pre‐transfusion testing results to eliminate delays of awaiting contemporaneous cross‐matching. Primary outcome is the feasibility of delivering weekly transfusion. Secondary outcomes include HRQoL, functional activity measurements, RBC usage, and alloimmunization rates. A qualitative substudy explores patient and staff experiences.ResultsThe trial is open in Australia, Netherlands, and UK. The first patient was recruited in 2020. Inter‐country differences in providing RBCs are observed, including patient genotyping versus serological phenotyping to select compatible units.DiscussionThis pilot trial evaluates a novel personalized transfusion approach of weekly matched RBC transfusion and challenges the dogma of current routine pre‐transfusion matching practice. Findings on study feasibility, HRQoL, and physical functional outcomes and the qualitative substudy will inform the design of a larger definitive trial powered for clinical outcomes.

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Section: Discussionmentioning

confidence: 99%

Rethinking the transfusion pathway in myelodysplastic syndromes: Study protocol for a novel randomized feasibility n‐of‐1 trial of weekly‐interval red cell transfusion in myelodysplastic syndromes

Mo,

Wood,

Shortt

et al. 2024

Transfusion

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“…23 There is also increasing recognition that, in certain clinical settings, there is currently clinical equipoise and uncertainty about whether some patient populations may not benefit from restrictive transfusion. 24 In two small pilot randomized studies of patients with myelodysplastic syndromes, there were signals that maintaining a higher Hb over time using a liberal transfusion strategy may be associated with improved HRQoL, 25,26 however, these were chronically transfused outpatients with chronic anemia. Observational studies in surgical settings have reported variable correlations between degree of postoperative anemia on HRQoL varying from impaired HRQoL at 2 months post hip arthroplasty, 27 to no impact at 3 months post hepatic resection.…”

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confidence: 99%

“…Certainly, anemia in the elderly is associated with poorer HRQoL and physical function 23 . There is also increasing recognition that, in certain clinical settings, there is currently clinical equipoise and uncertainty about whether some patient populations may not benefit from restrictive transfusion 24 . In two small pilot randomized studies of patients with myelodysplastic syndromes, there were signals that maintaining a higher Hb over time using a liberal transfusion strategy may be associated with improved HRQoL, 25,26 however, these were chronically transfused outpatients with chronic anemia.…”

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confidence: 99%

Restrictive transfusion thresholds: Have we left patient‐centered outcomes behind?

Higgins

2022

Transfusion

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Lessons learned from patient outcomes when lowering hemoglobin transfusion thresholds during COVID-19 blood shortages

Qiao

Ray

Singh

et al. 2023

American Journal of Clinical Pathology

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Objectives This study examines whether patient outcomes were affected when the hemoglobin (Hb) transfusion threshold was lowered by 1 g/dL during COVID-19–related blood shortages. Methods Outcomes of lowered Hb thresholds (from <7 to <6 g/dL) were defined by 14-month intervals in 2 patient groups (prepandemic [January 2019-February 2020] and pandemic [April 2020-May 2021]). We evaluated patient admissions, pretransfusion (if transfused) or nadir admission (if not transfused) Hb levels between 5.0 and 8.0 g/dL, and total red blood cell (RBC) transfusions during admission (if transfused). Baseline variables and outcomes were selected from electronic health records. Primary COVID-19–related admissions were excluded. Regression analysis was conducted to determine outcomes. Results Those in the prepandemic group (1976) and pandemic group (1547) were transfused. Fewer RBCs (2186, vs 3337) were used in the prepandemic group than in the pandemic group, respectively. Those in the prepandemic group had significantly higher rates of hypertension and diabetes as well as more smokers. Significant differences were observed when comparing the number of procedures and incidence of sepsis between the patient groups. Similar patterns were observed for the not transfused and transfused subgroups. Conclusions Patient outcomes were not affected after implementing lower Hb pretransfusion thresholds. Although confounding factors were mitigated, some may have been associated with procedures or sepsis. Proactive patient blood management strategies during COVID-19–related blood shortages may include adopting lower Hb thresholds.

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Red cell transfusions: Is less always best?

Cited by 4 publications

References 58 publications

Rethinking the transfusion pathway in myelodysplastic syndromes: Study protocol for a novel randomized feasibility n‐of‐1 trial of weekly‐interval red cell transfusion in myelodysplastic syndromes

Rethinking the transfusion pathway in myelodysplastic syndromes: Study protocol for a novel randomized feasibility n‐of‐1 trial of weekly‐interval red cell transfusion in myelodysplastic syndromes

Restrictive transfusion thresholds: Have we left patient‐centered outcomes behind?

Lessons learned from patient outcomes when lowering hemoglobin transfusion thresholds during COVID-19 blood shortages

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