Safety and Cost Effectiveness of a 10 × 109/L Trigger for Prophylactic Platelet Transfusions Compared With the Traditional 20 × 109/L Trigger: A Prospective Comparative Trial in 105 Patients With Acute Myeloid Leukemia

Abstract

In 105 consecutive patients with de novo acute myeloid leukemia (French-American-British M3 excluded), we compared prospectively the risk of bleeding complications, the number of platelet and red blood cell transfusions administered, and the costs of transfusions using two different prophylactic platelet transfusion protocols. Two hundred sixteen cycles of induction or consolidation chemotherapy and 3,843 days of thrombocytopenia less than 25 × 109/L were evaluated. At the start of the study, each of the 17 participating centers decided whether they would use a 10 × 109/L prophylactic platelet transfusion trigger (group A/8 centers) or a 20 × 109/L trigger (group B/9 centers). Bleeding complications (World Health Organization grade 2-4) during treatment cycles were comparable in the two groups: 20 of 110 (18%) in group A and 18 of 106 (17%) in group B (P = .8). Serious bleeding events (grade 3-4) were generally not related to the patient's platelet count but were the consequence of local lesions and plasma coagulation factor deficiencies due to sepsis. Eighty-six percent of the serious bleeding episodes occurred during induction chemotherapy. No patient died of a bleeding complication. There were no significant differences in the number of red blood cell transfusions administered between the two groups, but there were significant differences in the number of platelet transfusions administered per treatment cycle: pooled random donor platelet concentrates averaged 15.4 versus 25.4 (P < .01) and apheresis platelets averaged 3.0 versus 4.8 (P < .05) for group A versus group B, respectively. This resulted in the cost of platelet therapy being one third lower in group A compared with group B without any associated increase in bleeding risk.

The assessment of platelet function

“…Platelet count is a simple yet useful screening test. Platelet count below 20 × 10 9 /L is regarded as a trigger point for platelet transfusion in adult acute leukemia patients, 7 and a platelet count below 100 × 10 9 /L is often associated with increased bleeding after CPB. 8,9 A low platelet count has been shown to be a negative predictor of survival in critically ill patients.…”

The role of lectins and glycans in platelet clearance

“…Undeniably, clinical experience shows that transfused platelets work. Improvements in treatment have rendered fatal haemorrhage less common today, although thrombocytopenic patients receiving prophylactic transfusions in randomised platelet ÔtriggerÕ trials have had clinically significant bleeding complications (WHO Grades 2-4), at rates of 17-21.5%, irrespective of study arm [4,5]. Therefore, it seems reasonable to question whether current bleeding-rates could be reduced by improved platelet products.…”

Compliance with prophylactic platelet transfusion trigger in haematological patients

“…For a long time, a threshold of 20 Â 10 9 L À 1 has been used (Gaydos et al, 1962). The last decade, several comparative studies showed that the transfusion trigger can safely be lowered to 10 Â 10 9 L À 1 (Heckman et al, 1997;Rebulla et al, 1997;Wandt et al, 1998). Recent guidelines for the use of prophylactic platelet transfusions have adopted the threshold of 10 Â 10 9 L À 1 , which is as safe as higher levels for patients without additional risk factors.…”

“…The transfusion trigger is an important determinant of the number of transfusions (Heckman et al, 1997;Rebulla et al, 1997;Wandt et al, 1998;British Committee for Standards in Haematology, 2003). Lowering the transfusion trigger to 10 Â 10 9 L À 1 and strict compliance with this trigger may save costs and unnecessary exposure to the risks of transfusion-related complications like allergic or febrile transfusion reactions, transmission of infections and allo-immunization.…”