Transfusion therapy risks

Scothorn DJ, Price C, Schawartz D, et al. Risk of recurrent stroke in children with sickle cell disease receiving blood transfusion therapy for at least five years after initial stroke. J Pediatr 2002 140 348-354. 

Albumin (human) Epoetin alfa contains albumin, a derivative of human blood. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral diseases. No cases of transmission of viral diseases or Creutzfeldt-Jakob disease have ever been identified for albumin. Anemia Not intended for CRF patients who require correction of severe anemia epoetin alfa may obviate the need for maintenance transfusions but is not a substitute for emergency transfusion. Not indicated for treatment of anemia in HIV-infected patients or cancer patients due to other factors such as iron or folate deficiencies, hemolysis, or Gl bleeding, which should be managed appropriately. Hypertension Up to 80% of patients with CRF have a history of hypertension. Do not treat patients with uncontrolled hypertension monitor blood pressure adequately before initiation of therapy. Hypertensive encephalopathy and seizures have occurred in patients with CRF treated with epoetin. 

F. Role in therapy According to Micro-medex, treatment of severe chemotherapy-related thrombocytopenia is hmited to platelet transfusions. There is a need for an alternative, especially due to the frequent use of myeloid colony-stimulating factors (G-CSF, GM-CSF) to reduce febrile neutropenia although effective, their use increases the risk of acute and prolonged thrombocytopenia, and the need for platelet transfusions. Other cytokines, such as interleukin-1 and interleukin-6, have been investigated as a means of ameliorating chemotherapy-induced thrombocytopenia, but results have been equivocal. 

For many years, blood transfusion has been a therapy for children and adults with sickle cell disease. Prior to the 1980s, due to the lack of availability of blood products and the standard of care at that time, transfusion was used infrequently and generally only for catastrophic complications of this disease. During the 1980s, the risk of infection through transfusion was so high that transfusion continued to be used infrequently. When reliable testing for infectious diseases (e.g., HTV and hepatitis) in blood products became available, the use of red cell transfusion became standard of care for complications of sickle cell disease. 

Fractionation techniques have made it possible to recover active o -antitrypsin from blood. Use of this product for intravenous replacement therapy in deficient individuals has shown that it is possible to increase levels in the serum to those of PISZ heterozygotes who experience no increase in pulmonary disease over the general population. Pulmonary lavage of patients transfused with this product showed that functional (Xj-antitrypsin reaches the alveolar structures. The Food and Drug Administration has approved weekly administration of purified serum-derived oq-antitrypsin to PIZZ and PI null individuals with pulmonary disease. Although serum levels of oq-antitrypsin increase to those believed to be protective, it has not been possible to show clinical improvement. Furthermore, viral transmission via blood products is a significant risk factor. 

The use of recombinantly produced (X,-antitrypsin would reduce the risk of transfusion-related viral disease however, its half-life is too short to produce adequate serum levels without daily infusion. Studies have shown that the recombinant product can be administered as an aerosol. It diffuses across the respiratory epithelium, enters the lung lymph, and eventually reaches the systemic circulation. Unfortunately, it is not known whether this therapy has any influence on the development or progression of emphysema. Further carefully controlled, multicenter trials are necessary. 

In the past, hemophiliacs were treated with transfusions of a concentrated plasma fraction containing factor VIII. This therapy carried the risk of infection. Indeed, many hemophiliacs contracted hepatitis and AIDS. A safer preparation of factor VIII was urgently needed. With the use of biochemical purification and recombinant DNA techniques, the gene for factor VIII was isolated and expressed in cells grown in culture. Recombinant factor VIII purified from these cells has largely replaced plasma concentrates in treating hemophilia. 

Adverse effects. Haemorrhage occurs but is less of a problem with low doses of heparin it remains a particular risk in patients treated after failed fibrinol5 c therapy for acute myocardial infarction. Platelet transfusion after cessation of abciximab is necessary for refractory or life threatening bleeding. After transfusion, the antibody redistributes to the transfused platelets, reduces the mean level of receptor blockade and improves platelet function. Thrombocytopenia may occur from 1 hour to days after commencing treatment in up to 1% of patients. This necessitates platelet counts at 2-4 hours and then daily if severe, therapy must be stopped and, if necessary, platelets transfused. EDTA-induced pseudothrombocytopenia has been reported and a low platelet count should prompt examination of a blood film for agglutination before therapy is stopped. 

Ironside JW (2006) Variant Creutzfeldt-Jakob disease Risk of transmission by blood transfusion and blood therapies. Haemophilia 12(Suppl 1) 8-15. 

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... 

The treatment of ACD is somewhat less specific than the treatment of other anemias. Focus should be on treating the underlying disorder and correcting reversible causes of anemia. Direct approaches to correction of anemia may not be needed. During inflammation, oral or parenteral iron therapy is ineffective. Transfusions of RBCs are effective, but should be limited to situations in which oxygen transport is inadequate due to concomitant medical problems. The Hgb level necessitating a RBC transfusion varies from 8 to 10 g/dL based on factors such as cost, convenience, and risk of infectious complications. Assessment of the symptomatic state should always be considered before blood products are administered. 

Treatment of anemia of critical illness has nonspecific goals of therapy. The role of monitoring RBCs, Hgb, Hcfi EPO levels, and reticulocyte counts remains to be determined. Outcomes used in EPO studies are transfusion requirements and transfusion independence. Morbidity, mortality, and length of stay are also assessed. Adverse effects such as risk of thrombotic events must be monitored. More research is needed to determine whether reduction in RBC transfusions and increases in Hgb will result in improved clinical outcomes. 

For ACD, EPO is effective and safe, but expensive. Cost of IV iron is low compared with the cost of EPO. ince most patients are not symptomatic from this type of anemia, patients may actually feel no improvement with therapy. ymptom severity should be considered in the decision to use EPO. One study in patients with heart failure found use of erythropoietin to be highly cost-effective. Transfusion use for ACD as an alternative to EPO must take into consideration cost, convenience, and risk of complications. 

Due to the intense therapy received by children with AML, they are at risk for a variety of long-term sequelae. A recent study reported that more than 50% of survivors have growth abnormalities. Other findings include neurocognitive deficits, transfusion-associated hepatitis, endocrine disorders, cataracts, and cardiomyopathy (median cumulative anthracychne dose 335 mg/m ). The 20-year cumulative risk for a second mahgnancy is estimated to be 1.8%. 

---