Transfusion requirements

Aprotinin. Aprotinin is a naturally occurring serine protease inhibitor, has found widespread applications either by the intravenous route or as a component of biological sealants, because of its ability to decrease blood loss, and, as a consequence, transfusion requirements. Anaphylactic reactions are mediated by IgG and IgE antibodies. The risk of anaphylactic reactions has been estimated between 0.5 and 5.8% when used intravenously during cardiac surgery, and at 5 for 100,000 applications when used as a biologic sealant [25]. Patients previously treated with this drug present an increased risk and any new administration should be avoided for at least 6 months following an initial exposure [25]. 

Therapy with epoetin or darbepoetin can increase hemoglobin, decrease transfusion requirements, and improve quality of life in cancer and kidney disease patients with anemia. 

Studies have shown that in patients with chemotherapy-related anemia, therapy with erythropoietin products (epoetin-alfa and darbepoetin) can increase hemoglobin, decrease transfusion requirements, and improve quality of life.12 Epoetin is recombinant human erythropoietin, and darbepoetin is structurally similar to endogenous erythropoietin. Both bind to the same receptor to stimulate red blood cell production. Darbepoetin differs from epoetin in that it is a glycosylated form and exhibits a longer half-life in the body. The half-lives of a single subcutaneous injection of epoetin or darbepoetin in patients are roughly 27 and 43 hours, respectively. 

Treatment of anaemia associated with chronic disease Treatment of anaemia associated with cancer/chemotherapy Treatment of anaemia associated with prematurity To facilitate autologous blood donations before surgery To reduce transfusion requirements after surgery To prevent anaemia after bone marrow transplantation... 

Severe, and in particular chronic, infection can also sometimes induce anaemia, which is often made worse by drugs used to combat the infection. For example, anaemia is evident in 8 per cent of patients with asymptomatic HIV infection. This incidence increases to 20 per cent for those with AIDS-related complex, and is greater than 60 per cent for patients who have developed Kaposi s sarcoma. Up to a third of AIDS patients treated with zidovudine also develop anaemia. Again, several trials have confirmed that EPO treatment of AIDS sufferers (be they receiving zidovudine or not) can increase haematocrit values and decrease transfusion requirements. 

If the response is not satisfactory in terms of reducing transfusion requirements or increasing hematocrit after 8 weeks of therapy, the dose can be increased by 50 to 100 units/kg 3 times/week. Evaluate response every 4 to 8 weeks thereafter and adjust the dose accordingly by 50 to 100 units/kg increments 3 times/week. If patients have not responded satisfactorily to a 300 units/kg dose 3 times/week, it is unlikely that they will respond to higher doses. 

Increase dose if Response is not satisfactory (no reduction in transfusion requirements or rise in hemoglobin) after 8 weeks increase dose to 300 units/kg 3 times/week. 

Babies, especially babies born prematurely, often exhibit anaemia, which is characterized by a steadily decreasing serum haemoglobin level during the first 8 weeks of life. While multiple factors contribute to development of anaemia of prematurity, a lower than normal serum EPO level is a characteristic trait. In vitro studies indicate that BFU-E and CFU-E cells from such babies are responsive to EPO, and several pilot clinical trials have been initiated. Administration of 300-600 lU EPO/kg/week generally was found to enhance erythropoiesis and reduced the number of transfusions required by up to 30%. 

Leontiadis GI, Sharma VK, Howden CW. Systematic review and meta-analysis proton pump inhibitor treatment for ulcer bleeding reduces transfusion requirements and hospital stay-results from the Cochrane Collaboration. Aliment Pharmacol Ther 2005 22 169-74. 

Anemia of chronic disease is the second most common form of anemia. Recombinant erythropoietin frequently corrects the anemia with few or no transfusions. Anemia may also develop during radiotherapy or chemotherapy. Recombinant erythropoietin has been shown to increase hematocrit and decrease transfusion requirements after the first month of therapy in anemic cancer patients undergoing chemotherapy. 

Interleukin-11 is approved for the secondary prevention of thrombocytopenia in patients receiving cytotoxic chemotherapy for treatment of nonmyeloid cancers. Clinical trials show that it reduces the number of platelet transfusions required by... 

There are isolated reports of thromboembolic complications in recipients of desmopressin most occurred in patients with pre-existing vascular disease. However, in nine trials of the hemostatic efficacy of desmopressin in reducing blood and transfusion requirements in 763 patients, there were no significant differences between the frequencies of thromboembolism in subjects treated with desmopressin and controls (33). An analysis of 31 clinical trials of desmopressin in patients undergoing cardiac, vascular, orthopedic, or other major surgery showed that desmopressin did not increase the incidence of thrombosis (34). 

Interleukin-11 is the first growth factor to gain FDA approval for treatment of thrombocytopenia. It is approved for the secondary prevention of thrombocytopenia in patients receiving cytotoxic chemotherapy for treatment of nonmyeloid cancers. Clinical trials show that it reduces the number of platelet transfusions required by patients who experienced severe thrombocytopenia after a previous cycle of chemotherapy. Although IL-11 has broad stimulatory effects on hematopoietic cell lineages in vitro, it does not appear to have significant effects on the leukopenia or neutropenia caused by myelosuppressive chemotherapy. Interleukin-11 is given by subcutaneous injection at a dose of 50 g/kg/d. It is started 6-24 hours after completion of chemotherapy and continued for 14-21 days or until the platelet count passes the nadir and rises to > 50,000 cells/ L. 

Aminocaproic acid used during cardiopulmonary bypass reduced mediastinal blood losses by about one-third, while transfusion requirements were unchanged (41). In one series of over 950 patients, not a single thromboembolic complication could be ascribed to aminocaproic acid. However, a few cases of muscle necrosis and rhabdomyolysis with renal insufficiency have been reported with aminocaproic acid (42,43). 

Boylan JF, Klinck JR, Sandler AN, Arellano R, Greig PD, Nierenberg H, Roger SL, Glynn MF. Tranexamic acid reduces blood loss, transfusion requirements, and coagulation factor use in primary orthotopic liver transplantation. Anesthesiology 1996 85(5) 1043-8. 

Murkin JM, Lux J, Shannon NA, Guiraudon GM, Menkis AH, McKenzie FN, Novick RJ. Aprotinin significantly decreases bleeding and transfusion requirements in patients receiving aspirin and undergoing cardiac operations. J Thorac Cardiovasc Surg 1994 107(2) 554-61. 

MaUett SV, Cox D, Burroughs AK, RoUes K. Aprotinin and reduction of blood loss and transfusion requirements in orthotopic liver transplantation. Lancet 1990 336(8719) 886-7. 

Barrett-Lee PJ, Bailey NP, O Brien ME, Wager E. Large-scale UK audit of blood transfusion requirements and anaemia in patients receivmg cytotoxic chemotherapy. Br J Cancer 2000 82(l) 93-7. 

Recombinant human erythropoietin (epoetin and darbepoetin) provides effective therapy with a very favorable risk-benefit ratio in hemodialysis patients with end-stage chronic renal insufficiency, and in patients with progressive renal insufficiency who are not yet being dialysed (1). It improves cognitive function and the quality of life of patients with chronic uremia (2-5) and is very effective in children with chronic renal graft rejection and anemia (6). It also offers new opportunities for treating anemia in non-uremic patients. In patients with chemotherapy-induced anemia, epoetin increases hemoglobin concentration, reduces transfusion requirements, and improves quality of life (7,8). The response rate to epoetin in patients with multiple myeloma and anemia, which is 55-85% (9), increases when GM-CSF or G-CSF is... 

This patient had developed antibodies against recombinant erythropoietin. After recombinant erythropoietin was withdrawn, the concentration of antibodies fell slightly. Because of persistent transfusion requirements, she received prednisone (1 mg/kg/day) for 6 months. At that time, antibodies against erythropoietin could not be detected anymore and the hemoglobin concentration was around 5.6 mmol/1. 

In 30 preterm infants epoetin 300 ng/kg three times a week for 4 weeks reduced transfusion requirements without problems with tolerability (113). 

Epoetin can also be given orally in premature infants, resulting in a significant increase in plasma epoetin concentration, increased peak reticulocyte counts, and reduced blood transfusion requirements (62,81). 

Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled chnical trial of transfusion requirements in critical care. N Engl J Med 1999 340 409-417. 

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