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1.
J Clin Apher ; 35(4): 378-381, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32629539

RESUMO

As the COVID-19 pandemic continues to claim lives across the globe, insufficient data exists regarding the optimal treatment. It is well known that patients 55 years of age or older and patients with certain chronic diseases are at higher risk of severe illness, including acute respiratory distress syndrome and death. A potentially fatal pulmonary complication of sickle cell disease, acute chest syndrome, can be precipitated by acute infections, including respiratory viruses. We report the case of a patient with sickle cell disease (HbSC) who developed COVID-19 pneumonia and acute chest syndrome who was treated with emergent red blood cell exchange in order to avoid endotracheal intubation.


Assuntos
Anemia Falciforme/complicações , Betacoronavirus , Infecções por Coronavirus/complicações , Transfusão de Eritrócitos/métodos , Intubação Intratraqueal , Pandemias , Pneumonia Viral/complicações , Insuficiência Respiratória/terapia , Síndrome Torácica Aguda/etiologia , Síndrome Torácica Aguda/terapia , Adulto , Analgésicos/uso terapêutico , Antivirais/uso terapêutico , Azitromicina/uso terapêutico , Terapia Combinada , Contraindicações de Procedimentos , Infecções por Coronavirus/tratamento farmacológico , Humanos , Hidroxicloroquina/uso terapêutico , Masculino , Metilprednisolona/uso terapêutico , Oxigenoterapia , Pneumonia Viral/tratamento farmacológico , Respiração Artificial , Insuficiência Respiratória/etiologia
2.
Ann Hematol ; 99(9): 2047-2055, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32691114

RESUMO

Manual erythroexchange (MEEX) was proven to be effective and safe in the management of sickle cell disease (SCD). The goal is to quickly reduce the percentage of hemoglobin S (HbS%). A national survey of the Italian Society for Thalassemia and Hemoglobinopathies (SITE) observed a great variability among MEEX protocols none of which were found to be predictive of the values of HbS% and hemoglobin (Hb) after the exchange. Two equations to estimate the HbS% and Hb values to be obtained after MEEX were developed based on the results of the MEEX procedures in place in the centers participating in the present study. A standard protocol was subsequently defined to evaluate the volumes to exchange to obtain the target values of HbS% and Hb. The protocol was tested in 261 MEEX performed in SCD patients followed in the 5 participating centers that belong to the Italian Hemoglobinopathy Comprehensive Care Network, with the support of the SITE. The results showed a correlation between the estimated and measured values of HbS% and Hb (Rp 0.95 and 0.65 respectively, p < 0.001). A negligible bias was found for the prediction of HbS% and a bias of 1 g/dl for Hb. From consecutive MEEX, a rate of increase of HbS% between two exchanges of around 0.4% per day (p < 0.001) was measured. This protocol was shown to be effective and safe, as all patients reached the target value of HbS%. All the MEEX procedures were carried out with single venous access. No adverse events or reactions such as hypotension or electrolyte imbalance were reported nor were any complaints concerning the procedures received from patients.


Assuntos
Anemia Falciforme/sangue , Anemia Falciforme/terapia , Determinação do Volume Sanguíneo/normas , Volume Sanguíneo/fisiologia , Transfusão de Eritrócitos/normas , Hemoglobina Falciforme/metabolismo , Adulto , Anemia Falciforme/epidemiologia , Determinação do Volume Sanguíneo/métodos , Transfusão de Eritrócitos/métodos , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Adulto Jovem
3.
Lancet Haematol ; 7(6): e469-e478, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32470438

RESUMO

BACKGROUND: Transfusion-dependent haemoglobinopathies require lifelong iron chelation therapy with one of the three iron chelators (deferiprone, deferasirox, or deferoxamine). Deferasirox and deferiprone are the only two oral chelators used in adult patients with transfusion-dependent haemoglobinopathies. To our knowledge, there are no randomised clinical trials comparing deferiprone, a less expensive iron chelator, with deferasirox in paediatric patients. We aimed to show the non-inferiority of deferiprone versus deferasirox. METHODS: DEEP-2 was a phase 3, multicentre, randomised trial in paediatric patients (aged 1 month to 18 years) with transfusion-dependent haemoglobinopathies. The study was done in 21 research hospitals and universities in Italy, Egypt, Greece, Albania, Cyprus, Tunisia, and the UK. Participants were receiving at least 150 mL/kg per year of red blood cells for the past 2 years at the time of enrolment, and were receiving deferoxamine (<100 mg/kg per day) or deferasirox (<40 mg/kg per day; deferasirox is not registered for use in children aged <2 years so only deferoxamine was being used in these patients). Any previous chelation treatment was permitted with a 7-day washout period. Patients were randomly assigned 1:1 to receive orally administered daily deferiprone (75-100 mg/kg per day) or daily deferasirox (20-40 mg/kg per day) administered as dispersible tablets, both with dose adjustment for 12 months, stratified by age (<10 years and ≥10 years) and balanced by country. The primary efficacy endpoint was based on predefined success criteria for changes in serum ferritin concentration (all patients) and cardiac MRI T2-star (T2*; patients aged >10 years) to show non-inferiority of deferiprone versus deferasirox in the per-protocol population, defined as all randomly assigned patients who received the study drugs and had available data for both variables at baseline and after 1 year of treatment, without major protocol violations. Non-inferiority was based on the two-sided 95% CI of the difference in the proportion of patients with treatment success between the two groups and was shown if the lower limit of the two-sided 95% CI was greater than -12·5%. Safety was assessed in all patients who received at least one dose of study drug. This study is registered with EudraCT, 2012-000353-31, and ClinicalTrials.gov, NCT01825512. FINDINGS: 435 patients were enrolled between March 17, 2014, and June 16, 2016, 393 of whom were randomly assigned to a treatment group (194 to the deferiprone group; 199 to the deferasirox group). 352 (90%) of 390 patients had ß-thalassaemia major, 27 (7%) had sickle cell disease, five (1%) had thalassodrepanocytosis, and six (2%) had other haemoglobinopathies. Median follow-up was 379 days (IQR 294-392) for deferiprone and 381 days (350-392) for deferasirox. Non-inferiority of deferiprone versus deferasirox was established (treatment success in 69 [55·2%] of 125 patients assigned deferiprone with primary composite efficacy endpoint data available at baseline and 1 year vs 80 [54·8%] of 146 assigned deferasirox, difference 0·4%; 95% CI -11·9 to 12·6). No significant difference between the groups was shown in the occurrence of serious and drug-related adverse events. Three (2%) cases of reversible agranulocytosis occurred in the 193 patients in the safety analysis in the deferiprone group and two (1%) cases of reversible renal and urinary disorders (one case of each) occurred in the 197 patients in the deferasirox group. Compliance was similar between treatment groups: 183 (95%) of 193 patients in the deferiprone group versus 192 (97%) of 197 patients in the deferisirox group. INTERPRETATION: In paediatric patients with transfusion-dependent haemoglobinopathies, deferiprone was effective and safe in inducing control of iron overload during 12 months of treatment. Considering the need for availability of more chelation treatments in paediatric populations, deferiprone offers a valuable treatment option for this age group. FUNDING: EU Seventh Framework Programme.


Assuntos
Deferasirox/uso terapêutico , Deferiprona/uso terapêutico , Transfusão de Eritrócitos/métodos , Hemoglobinopatias/tratamento farmacológico , Quelantes de Ferro/uso terapêutico , Sobrecarga de Ferro/tratamento farmacológico , Administração Oral , Adolescente , Agranulocitose/induzido quimicamente , Agranulocitose/epidemiologia , Albânia/epidemiologia , Anemia Falciforme/terapia , Técnicas de Imagem Cardíaca/métodos , Criança , Pré-Escolar , Chipre/epidemiologia , Deferasirox/administração & dosagem , Deferasirox/economia , Deferiprona/administração & dosagem , Deferiprona/economia , Egito/epidemiologia , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Ferritinas/sangue , Ferritinas/efeitos dos fármacos , Grécia/epidemiologia , Hemoglobinopatias/terapia , Humanos , Lactente , Quelantes de Ferro/administração & dosagem , Quelantes de Ferro/economia , Sobrecarga de Ferro/sangue , Itália/epidemiologia , Imagem por Ressonância Magnética , Masculino , Cooperação do Paciente , Resultado do Tratamento , Tunísia/epidemiologia , Reino Unido/epidemiologia , Doenças Urológicas/induzido quimicamente , Doenças Urológicas/epidemiologia , Talassemia beta/terapia
4.
Transfusion ; 60(5): 922-931, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32358836

RESUMO

BACKGROUND: There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS: International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS: The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION: The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.


Assuntos
Transfusão de Sangue/economia , Transfusão de Sangue/métodos , Adolescente , Adulto , Contagem de Células Sanguíneas/economia , Plaquetas/citologia , Transfusão de Sangue/mortalidade , Transfusão de Sangue/estatística & dados numéricos , Análise Custo-Benefício , Contagem de Eritrócitos , Transfusão de Eritrócitos/economia , Transfusão de Eritrócitos/métodos , Transfusão de Eritrócitos/mortalidade , Transfusão de Eritrócitos/estatística & dados numéricos , Eritrócitos/citologia , Feminino , Hemorragia/sangue , Hemorragia/mortalidade , Hemorragia/terapia , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Plasma/citologia , Transfusão de Plaquetas/economia , Transfusão de Plaquetas/métodos , Transfusão de Plaquetas/mortalidade , Transfusão de Plaquetas/estatística & dados numéricos , Ressuscitação/mortalidade , Ressuscitação/estatística & dados numéricos , Adulto Jovem
6.
Anesth Analg ; 130(5): 1364-1380, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32167979

RESUMO

Anemia is common in the perioperative period and is associated with poor patient outcomes. Remarkably, anemia is frequently ignored until hemoglobin levels drop low enough to warrant a red blood cell transfusion. This simplified transfusion-based approach has unfortunately shifted clinical focus away from strategies to adequately prevent, diagnose, and treat anemia through direct management of the underlying cause(s). While recommendations have been published for the treatment of anemia before elective surgery, information regarding the design and implementation of evidence-based anemia management strategies is sparse. Moreover, anemia is not solely a concern of the preoperative encounter. Rather, anemia must be actively addressed throughout the perioperative spectrum of patient care. This article provides practical information regarding the implementation of anemia management strategies in surgical patients throughout the perioperative period. This includes evidence-based recommendations for the prevention, diagnosis, and treatment of anemia, including the utility of iron supplementation and erythropoiesis-stimulating agents (ESAs).


Assuntos
Anemia/diagnóstico , Anemia/prevenção & controle , Gerenciamento Clínico , Assistência Perioperatória/métodos , Anemia/sangue , Transfusão de Eritrócitos/métodos , Hematínicos/administração & dosagem , Humanos , Ferro/administração & dosagem , Ferro/sangue
7.
PLoS One ; 15(3): e0229566, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32155167

RESUMO

In porcine kidney auto-transplant models, red blood cells (RBCs) are required for ex-vivo normothermic machine perfusion (NMP). As large quantities of RBCs are needed for NMP, utilising autologous RBCs would imply lethal exsanguination of the pig that is donor and recipient-to-be in the same experiment. The purpose of this study was to determine if an isolated porcine kidney can also be perfused with allogeneic porcine or human RBCs instead. Porcine kidneys, autologous and allogeneic blood were obtained from a local slaughterhouse. Human RBCs (O-pos), were provided by our transfusion laboratory. Warm ischaemia time was standardised at 20 minutes and subsequent hypothermic machine perfusion lasted 1.5-2.5 hours. Next, kidneys underwent NMP at 37°C during 7 hours with Williams' Medium E and washed, leukocyte depleted RBCs of either autologous, allogeneic, or human origin (n = 5 per group). During perfusion all kidneys were functional and produced urine. No macroscopic adverse reactions were observed. Creatinine clearance during NMP was significantly higher in the human RBC group in comparison with the allogeneic group (P = 0.049) but not compared to the autologous group. The concentration of albumin in the urine was significantly higher in the human RBC group (P <0.001) compared to the autologous and allogeneic RBC group. Injury marker aspartate aminotransferase was significantly higher in the human RBC group in comparison with the allogeneic group (P = 0.040) but not in comparison with the autologous group. Renal histology revealed glomerular and tubular damage in all groups. Signs of pathological hyperfiltration and microvascular injury were only observed in the human RBC group. In conclusion, perfusion of porcine kidneys with RBCs of different origin proved technically feasible. However, laboratory analysis and histology revealed more damage in the human RBC group compared to the other two groups. These results indicate that the use of allogeneic RBCs is preferable to human RBCs in a situation where autologous RBCs cannot be used for NMP.


Assuntos
Transplante de Rim/métodos , Perfusão/métodos , Transplante Homólogo/métodos , Animais , Contagem de Eritrócitos , Transfusão de Eritrócitos/métodos , Eritrócitos/fisiologia , Feminino , Transplante de Células-Tronco Hematopoéticas , Humanos , Isquemia/patologia , Rim/patologia , Glomérulos Renais , Modelos Animais , Preservação de Órgãos/métodos , Suínos , Doadores de Tecidos , Isquemia Quente
8.
Rev Med Suisse ; 16(680): 260-263, 2020 Feb 05.
Artigo em Francês | MEDLINE | ID: mdl-32022490

RESUMO

International guidelines suggest that a liberal transfusion policy is not only unnecessary but can also prove harmful in certain situations. Blood transfusion is a costly act involving risks of infection, allergic and hemodynamic. Optimizing the use of this scarce and expensive resource becomes necessary. The case report depicts perfectly the potential complications of a transfusion policy considered too liberal, while emphasizing the importance of clinical judgment in each situation.


Assuntos
Transfusão de Eritrócitos/efeitos adversos , Transfusão de Eritrócitos/normas , Transfusão de Eritrócitos/métodos , Humanos
9.
Transfusion ; 60(3): 513-523, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32064619

RESUMO

BACKGROUND: Red blood cell (RBC) transfusions result in the sequestration and metabolism of storage-damaged RBCs within the spleen and liver. These events are followed by increased plasma iron concentrations that can contribute to oxidant stress and cellular injury. We hypothesized that administration of a ferroportin inhibitor (FPN-INH) immediately after acute RBC exchange transfusion could attenuate posttransfusion circulatory compartment iron exposure, by retaining iron in spleen and hepatic macrophages. STUDY DESIGN AND METHODS: Donor guinea pig blood was leukoreduced, and RBCs were preserved at 4°C. Recipient guinea pigs (n = 5/group) were exchange transfused with donor RBCs after refrigerator preservation and dosed intravenously with a small-molecule FPN-INH. Groups included transfusion with vehicle (saline), 5 mg/kg or 25 mg/kg FPN-INH. A time course of RBC morphology, plasma non-transferrin-bound iron (NTBI) and plasma hemoglobin (Hb) were evaluated. End-study spleen, liver, and kidney organ iron levels, as well as renal tissue oxidation and injury, were measured acutely (24-hr after transfusion). RESULTS: RBC transfusion increased plasma NTBI, with maximal concentrations occurring 8 hours after transfusion. Posttransfusion iron accumulation resulted in tubule oxidation and acute kidney injury. FPN inhibition increased spleen and liver parenchymal/macrophage iron accumulation, but attenuated plasma NTBI, and subsequent renal tissue oxidation/injury. CONCLUSION: In situations of acute RBC transfusion, minimizing circulatory NTBI exposure by FPN inhibition may attenuate organ-specific adverse consequences of iron exposure.


Assuntos
Proteínas de Transporte de Cátions/metabolismo , Ferro/sangue , Animais , Preservação de Sangue , Proteínas de Transporte de Cátions/antagonistas & inibidores , Transfusão de Eritrócitos/métodos , Cobaias , Humanos , Masculino , Estresse Oxidativo/fisiologia
10.
Transfusion ; 60(3): 535-543, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32067239

RESUMO

BACKGROUND: Blood products are essential for modern medicine, but managing their collection and supply in the face of fluctuating demands represents a major challenge. As deterministic models based on predicted changes in population have been problematic, there remains a need for more precise and reliable prediction of demands. Here, we propose a paradigm incorporating four different time-series methods to predict red blood cell (RBC) issues 4 to 24 weeks ahead. STUDY DESIGN AND METHODS: We used daily aggregates of RBC units issued from 2005 to 2011 from the National Health Service Blood and Transplant. We generated a new set of nonoverlapping weekly data by summing the daily data over 7 days and derived the average blood issues per week over 4-week periods. We used four methods for linear prediction of blood demand by computing the coefficients with the minimum mean squared error and weighted least squares error algorithms. RESULTS: We optimized the time-window size, order of the prediction, and order of the polynomial fit for our data set. The four time-series methods, essentially using different weightings to data points, gave very similar results and predicted mean RBC issues with a standard deviation of the percentage error of 3.0% for 4 weeks ahead and 4.0% for 24 weeks ahead. CONCLUSION: This paradigm allows prediction of demand for RBCs and could be developed to provide reliable and precise prediction up to 24 weeks ahead to improve the efficiency of blood services and sufficiency of blood supply with reduced costs.


Assuntos
Transfusão de Eritrócitos/métodos , Eritrócitos , Algoritmos , Inglaterra , Humanos , Análise dos Mínimos Quadrados
11.
Transfusion ; 60(4): 724-730, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32056229

RESUMO

BACKGROUND: Red blood cell (RBC) transfusion support is essential in patients with acute leukemia (AL). A restrictive RBC transfusion approach is assumed to be safe for most individuals with AL. The aim of this audit was to assess RBC transfusion appropriateness in AL patients at an academic center. STUDY DESIGN AND METHODS: RBC transfusions in acute lymphoblastic leukemia and acute myeloid leukemia patients of all ages between January 1, 2013, and March 31, 2019, were analyzed for adherence to evidence-based criteria. Transfusion appropriateness was compared among ordering specialties, patient locations, and hematologic diagnoses. Pretransfusion hemoglobin was compared between categories. Overtransfusion rates were also analyzed. Descriptive statistics and categorical and numerical tests were employed to determine statistical significance. RESULTS: A total of 510 RBC transfusions were received by 133 AL patients in the departments of internal medicine, hematology, and pediatrics. Overall, 84.5% were appropriate according to established criteria. Internal medicine was the ordering department with the highest rate of appropriateness (88.1%). The outpatient clinic was the location with the highest adherence (85.9%), whereas the intensive care unit had the lowest (70%; p = 0.03). The reasons for most appropriate and inappropriate transfusions were asymptomatic anemia with a hemoglobin below (60.6%) or above (69.6%) 7 g/dL in patients without cardiac disease, respectively. Overtransfusion was present in 22% of episodes. CONCLUSION: RBC transfusion in AL patients reflected good adherence to guidelines. However, continuing education in transfusion medicine and prospective chart auditing are needed to improve adherence to established guidelines.


Assuntos
Transfusão de Eritrócitos/métodos , Fidelidade a Diretrizes/estatística & dados numéricos , Leucemia Mieloide Aguda/terapia , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Anemia/sangue , Transfusão de Eritrócitos/normas , Transfusão de Eritrócitos/estatística & dados numéricos , Cardiopatias/sangue , Hemoglobinas/análise , Hospitais Universitários , Humanos , Leucemia-Linfoma Linfoblástico de Células Precursoras/complicações , Atenção Terciária à Saúde
12.
Medicine (Baltimore) ; 99(2): e18739, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31914091

RESUMO

Autoimmune hemolytic anemia (AIHA) is a rare disease in which autoantibodies target red blood cells (RBCs), leading to anemia that ranges from no symptoms to severe life-threatening hemolysis. Little is known about the severity of anemia, blood transfusion efficiency and risk of transfusion-related reactions among hospitalized AIHA patients, especially in those with incompatible RBC transfusions.A retrospective study was conducted among hospitalized AIHA patients from January 2009 to December 2015 in a large tertiary care medical center in southwest China.A total of 450 AIHA hospitalized patients were recruited, of whom 97.3% had warm AIHA, 30.3% had primary AIHA, and 90.7% were treated with corticosteroids. On admission, approximately 3% of patients had an hemoglobin (Hb) <30 g/L, 34% had an Hb between 30 and 59.9 g/L, and 46% had an Hb ranging from 60 to 89.9 g/L. A total of 2509.5 U RBCs were transfused to AIHA patients, and 14 transfusion-related adverse reactions were recorded, without any hemolytic transfusion reactions. With an average transfusion trigger of 52.0 ±â€Š9.3 g/L, 59.7% of the patients received RBCs, and 55.8% of the transfusions were viewed as effective. Least incompatible RBCs were given in 39% of the transfusions, but the transfusion efficiency did not significantly decrease with these incompatible blood transfusions (P = .253). Primary AIHA patients with a nadir Hb of approximately 40 to 50 g/L during their hospital stay had the highest rate of remission and did not require a different total number of RBC transfusions (P = .068) or length of hospitalization (P = .194) compared to other groups with nadir Hb values <30 g/L, ≥30 and <40 g/L, ≥50 and <60 g/L, and ≥60 g/L.One-third of AIHA patients suffered from severe anemia during hospitalization, and transfusions, even with incompatible RBCs, were safe and efficient. However, transfusion triggers between 40 and 50 g/L seemed to benefit the most patients by alleviating the RBC destruction caused by autoantibodies, and a restrictive transfusion strategy was beneficial in AIHA patients.


Assuntos
Corticosteroides/uso terapêutico , Anemia Hemolítica Autoimune/fisiopatologia , Anemia Hemolítica Autoimune/terapia , Transfusão de Eritrócitos/métodos , Corticosteroides/administração & dosagem , Corticosteroides/efeitos adversos , Adulto , Anemia Hemolítica Autoimune/epidemiologia , Transfusão de Eritrócitos/efeitos adversos , Feminino , Hemoglobinas , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Reação Transfusional/epidemiologia
13.
Blood Adv ; 4(2): 327-355, 2020 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-31985807

RESUMO

BACKGROUND: Red cell transfusions remain a mainstay of therapy for patients with sickle cell disease (SCD), but pose significant clinical challenges. Guidance for specific indications and administration of transfusion, as well as screening, prevention, and management of alloimmunization, delayed hemolytic transfusion reactions (DHTRs), and iron overload may improve outcomes. OBJECTIVE: Our objective was to develop evidence-based guidelines to support patients, clinicians, and other healthcare professionals in their decisions about transfusion support for SCD and the management of transfusion-related complications. METHODS: The American Society of Hematology formed a multidisciplinary panel that was balanced to minimize bias from conflicts of interest and that included a patient representative. The panel prioritized clinical questions and outcomes. The Mayo Clinic Evidence-Based Practice Research Program supported the guideline development process. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to form recommendations, which were subject to public comment. RESULTS: The panel developed 10 recommendations focused on red cell antigen typing and matching, indications, and mode of administration (simple vs red cell exchange), as well as screening, prevention, and management of alloimmunization, DHTRs, and iron overload. CONCLUSIONS: The majority of panel recommendations were conditional due to the paucity of direct, high-certainty evidence for outcomes of interest. Research priorities were identified, including prospective studies to understand the role of serologic vs genotypic red cell matching, the mechanism of HTRs resulting from specific alloantigens to inform therapy, the role and timing of regular transfusions during pregnancy for women, and the optimal treatment of transfusional iron overload in SCD.


Assuntos
Anemia Falciforme/terapia , Transfusão de Eritrócitos/métodos , Tipagem e Reações Cruzadas Sanguíneas , Medicina Baseada em Evidências , Humanos , Sobrecarga de Ferro/prevenção & controle , Sobrecarga de Ferro/terapia , Reação Transfusional/prevenção & controle , Reação Transfusional/terapia
14.
Transfusion ; 60(2): 358-366, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31930533

RESUMO

BACKGROUND: The nucleic acid targeted pathogen reduction (PR) system utilizing amustaline (S-303) and glutathione (GSH) is designed to inactivate blood-borne pathogens and leukocytes in red blood cell concentrates (PR-RBCC). Inactivation is attained after amustaline intercalates and forms covalent nucleic acid adducts preventing replication, transcription, and translation. After pathogen inactivation, amustaline spontaneously hydrolyzes to S-300, the primary negatively charged reaction product; amustaline is below quantifiable levels in PR-RBCC. GSH quenches free unreacted amustaline. STUDY DESIGN AND METHODS: The genotoxic and carcinogenic potential of PR-RBCC, the reaction by-products, and S-300 were assessed in accordance with the International Conference on Harmonization (ICH) guidelines and performed in compliance with the Food and Drug Administration (FDA) good laboratory practice standards, 21 CFR Part 58. in vitro bacterial reverse mutagenicity and chromosomal aberration assays were performed with and without exogenous S9 metabolic activation, and in in vivo clastogenicity and carcinogenic assays using validated murine models. RESULTS: PR-RBCCs were not genotoxic in vitro and in vivo and were non-carcinogenic in p53+/- transgenic mice transfused over 26 weeks. Estimated safety margins for human exposure ranged from >90 to >36 fold for 2 to 5 PR-RBCCs per day, respectively. PR-RBCCs and S-300 did not induce chromosome aberration in the in vivo murine bone marrow micronucleus assay at systemically toxic doses. CONCLUSIONS: PR-RBCCs did not demonstrate genotoxicity in vitro or in vivo and were not carcinogenic in vivo. These studies support the safety of PR-RBCCs and suggest that there is no measurable genotoxic hazard associated with transfusion of PR-RBCCs.


Assuntos
Acridinas/farmacologia , Eritrócitos/efeitos dos fármacos , Eritrócitos/metabolismo , Glutationa/farmacologia , Compostos de Mostarda Nitrogenada/farmacologia , Animais , Patógenos Transmitidos pelo Sangue/efeitos dos fármacos , Transfusão de Eritrócitos/métodos , Feminino , Humanos , Linfócitos/efeitos dos fármacos , Linfócitos/metabolismo , Masculino , Camundongos , Testes para Micronúcleos , Proteína Supressora de Tumor p53/genética , Proteína Supressora de Tumor p53/metabolismo , Inativação de Vírus/efeitos dos fármacos
15.
Crit Care ; 24(1): 18, 2020 01 17.
Artigo em Inglês | MEDLINE | ID: mdl-31952555

RESUMO

PURPOSE: Hemoglobin (Hb) transfusion thresholds are established in intensive care units. A restrictive transfusion threshold (Hb 70-75 g/l) is recommended in septic patients, and a liberal transfusion threshold (Hb 90 g/l) for cardiogenic shock. It is unclear whether these historically adopted transfusion thresholds meet the challenges of individual patients. METHODS: We evaluated microvascular flow index (MFI) and proportion of perfused vessels (PPV) in the sublingual microcirculation with CytoCam-IDF microscopy and near-infrared spectroscopy (NIRS). A study team-independent, treating intensivist assigned a total of 64 patients to 1 of 2 two transfusion thresholds, 43 patients to the Hb 75 g/l threshold and 21 patients to the Hb 90 g/l threshold, at a surgical intensive care unit. We performed microcirculatory measurements 1 h before and 1 h after transfusion of 1 unit of red blood cells. RESULTS: Microcirculatory flow variables correlated negatively with pre-transfusion flow variables (ΔMFI: ρ = - 0.821, p <  0.001; ΔPPV: ρ = - 0.778, p <  0.001). Patients with good initial microcirculation (cutoffs: MFI > 2.84, PPV > 88%) showed a deteriorated microcirculation after red blood cell transfusion. An impaired microcirculation improved after transfusion. At both transfusion thresholds, approximately one third of the patients showed an initially impaired microcirculation. In contrast, one third in every group had good microcirculation above the cutoff variables and did not profit from the transfusion. CONCLUSION: The data suggest that the established transfusion thresholds and other hemodynamic variables do not reflect microcirculatory perfusion of patients. Blood transfusion at both thresholds 75 g/l and 90 g/l hemoglobin can either improve or harm the microcirculatory blood flow, questioning the concept of arbitrary transfusion thresholds.


Assuntos
Transfusão de Eritrócitos/classificação , Soalho Bucal/irrigação sanguínea , Idoso , Transfusão de Eritrócitos/métodos , Transfusão de Eritrócitos/tendências , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Microcirculação/fisiologia , Pessoa de Meia-Idade , Soalho Bucal/fisiopatologia , Estudos Prospectivos , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Medicina Transfusional/métodos , Medicina Transfusional/normas
16.
Gynecol Oncol ; 156(2): 439-445, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31839344

RESUMO

BACKGROUND: The impact of perioperative red blood cell transfusion (PRBCT) on cancer survival has remained controversial. METHODS: We conducted a retrospective study in patients undergoing primary debulking surgery (PDS) for ovarian cancer between January 2013 and December 2017. The patients were divided into two groups based on whether they received PRBCT. Clinical characteristics were compared between groups. After propensity score matching, perioperative systemic inflammation-based scores, quality of recovery, postoperative outcomes, disease-free survival (DFS), and overall survival (OS) were compared between groups. Univariate and multivariable Cox proportional hazard models were used to evaluate the association between covariates and survival outcomes. RESULTS: A total of 1037 patients were enrolled in this study, and 31.7% of patients received PRBCT. After propensity matching, there was no significant difference in the clinical characteristics between groups. Patients receiving PRBCT had more postoperative fluctuations in systemic inflammatory response-related indicators (P < 0.001), a higher incidence of postoperative grade II complications (28.4% vs. 14.8%), a longer length of stay (10.6 d vs. 6.2 d) and higher 30-day and total readmission rates (7.1% vs. 4.4% and 11.2% vs. 8.1%, P < 0.001, respectively) than patients who did not receive PRBCT. The OS and DFS rates 3 years after surgery were significantly lower in the patients receiving PRBCT than in patients not receiving PRBCT (58.9% vs. 74.5%, 39.6% vs. 52.3%). CONCLUSIONS: PRBCT was significantly associated with more fluctuations in systemic inflammatory indicators, a prolonged length of stay, higher postoperative complication rates and increased cancer recurrence and overall mortality in ovarian cancer patients undergoing PDS.


Assuntos
Transfusão de Eritrócitos/estatística & dados numéricos , Neoplasias Ovarianas/terapia , Estudos de Coortes , Intervalo Livre de Doença , Transfusão de Eritrócitos/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Ovarianas/sangue , Neoplasias Ovarianas/mortalidade , Neoplasias Ovarianas/cirurgia , Assistência Perioperatória/métodos , Assistência Perioperatória/estatística & dados numéricos , Período Pós-Operatório , Pontuação de Propensão , Estudos Retrospectivos , Resultado do Tratamento
17.
Anaesthesia ; 75(4): 455-463, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31667830

RESUMO

Guidelines recommend restrictive red blood cell transfusion strategies. We conducted an observational study to examine whether the rate of peri-operative red blood cell transfusion in the USA had declined during the period from 01 January 2011 to 31 December 2016. We included 4,273,168 patients from all surgical subspecialties. We examined parallel trends in rates of the following: pre-operative transfusion; prevalence of bleeding disorders and coagulopathy; and minimally invasive procedures. To account for changes in population and procedure characteristics, we performed multivariable logistic regression to assess whether the risk of receiving a transfusion had declined over the study period. Clinical outcomes included peri-operative myocardial infarction, stroke and all-cause mortality at 30 days. Peri-operative red blood cell transfusion rates declined from 37,040/441,255 (8.4%) in 2011 to 46,845/1,000,195 (4.6%) in 2016 (p < 0.001) across all subspecialties. Compared with 2011, the corresponding adjusted OR (95%CI) for red blood cell transfusion decreased gradually from 0.88 (0.86-0.90) in 2012 to 0.51 (0.50-0.51) in 2016 (p < 0.001). Pre-operative red blood cell transfusion rates and the prevalence of bleeding disorders decreased, whereas haematocrit levels and the proportion of minimally invasive procedures increased. Compared with 2011, the adjusted hazard ratios (95%CI) in 2012 and 2016 were 0.96 (0.90-1.02) and 1.05 (0.99-1.11) for myocardial infarction, 0.91 (0.83-0.99) and 0.99 (0.92-1.07) for stroke and 0.98 (0.94-1.02) and 0.99 (0.96-1.03) for all-cause mortality. Use of peri-operative red blood cell transfusion declined from 2011 to 2016. This was not associated with an increase in adverse clinical outcomes.


Assuntos
Transfusão de Eritrócitos/estatística & dados numéricos , Cuidados Intraoperatórios/métodos , Cuidados Intraoperatórios/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Transfusão de Eritrócitos/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia
18.
Transfusion ; 60(2): 256-261, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31883275

RESUMO

BACKGROUND: Anemia is common in critically ill patients and associated with adverse outcomes. Phlebotomy associated with laboratory testing is a potentially modifiable contributor. This study aims to 1) characterize the blood volume taken for laboratory testing, and 2) explore the effect of blood loss on red blood cell (RBC) transfusion and anemia in adult intensive care unit (ICU) patients. METHODS: Using a transfusion research database, we retrospectively reviewed consecutively admitted patients to four medical-surgical ICUs in Hamilton, Ontario, Canada. The primary outcome was estimated blood loss for laboratory testing during ICU admission. Secondary outcomes were hemoglobin (Hb) of 90 g/L or less and RBC transfusion. RESULTS: Among the 7273 patients included, the median blood volume per patient taken for laboratory testing during their ICU stay was 213 mL (interquartile range [IQR], 133-382 mL). On ICU admission, median Hb was 97 g/L (IQR, 82-116 g/L). An Hb of 90 g/L or less occurred in 67.0% of patients during their ICU stay. Median Hb on ICU discharge adjusted for RBC transfusion was 84 g/L (IQR, 58-105 g/L). RBC transfusion was administered to 47.5% of patients, who received a median of 3 units (IQR, 2-7 units). Cumulative blood loss due to laboratory testing from Day 2 to Day 7 of ICU admission was independently associated with RBC transfusion (hazard ratio, 2.28 for each 150-mL increment; 95% confidence interval, 2.02-2.59). CONCLUSIONS: Blood loss for laboratory testing is substantial in ICU patients and significantly associated with RBC transfusion. Strategies to reduce blood loss from laboratory testing represents an area for further investigation.


Assuntos
Anemia/terapia , Transfusão de Eritrócitos/métodos , Hemorragia/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Idoso , Canadá , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ontário , Estudos Retrospectivos
19.
Anesth Analg ; 131(2): 483-493, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31880628

RESUMO

BACKGROUND: The relationships between the ratios of transfused allogeneic blood products and clinical outcomes in patients with acute intraoperative hemorrhage are poorly defined. METHODS: To better define these ratios, we undertook a single-center, observational cohort study of all surgical patients (≥18 years) who received rapid transfusion defined by a critical administration threshold of 3 or more units of red blood cells (RBCs) intraoperatively within 1 hour between January 1, 2011 and December 31, 2015. Multivariable regression analyses were used to assess relationships between ratios of plasma to RBCs and platelets to RBCs at 3, 12, and 24 hours and clinical outcomes. The primary outcome was hospital mortality, with secondary outcomes of intensive care unit and hospital-free days. RESULTS: The study included 2385 patients, of whom 14.9% had a plasma-to-RBC ratio of 1.0+, and 47.6% had a platelet-to-RBC ratio of 1.0+. Higher plasma-to-RBC and platelet-to-RBC ratios were observed for patients who underwent cardiac, transplant, and vascular surgery and in patients with greater derangements in hemostatic laboratory values. Ratios did not differ by patient age or severity of illness. Higher ratios were not associated with improved clinical outcomes. Mortality differed by platelet-to-RBC but not plasma-to-RBC ratio, with the highest mortality observed with a platelet-to-RBC ratio of 0.1-0.9 at 24 hours (odds ratio, 3.34 [1.62-6.88]) versus no platelets (P= .001). Higher plasma-to-RBC ratios were associated with decreased hospital-free days, although differences in clinical outcomes were not significant after exclusion of patients receiving only RBCs without component therapies. CONCLUSIONS: Transfusion ratios in surgical patients with critical intraoperative hemorrhage were largely related to surgical and hemostatic features rather than baseline patient characteristics. Higher ratios were not associated with improved outcomes.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Plaquetas/metabolismo , Transfusão de Sangue Autóloga/métodos , Complicações Intraoperatórias/sangue , Complicações Intraoperatórias/terapia , Plasma/metabolismo , Idoso , Estudos de Coortes , Transfusão de Eritrócitos/métodos , Feminino , Humanos , Unidades de Terapia Intensiva/tendências , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
20.
Semin Hematol ; 56(4): 236-240, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31836029

RESUMO

Red cell genotyping has become widely available and now contributes to support transfusion of patients with hematologic diseases. This technology has facilitated the immunohematologic approach to antibody prevention, detection and identification. Donors, particularly rare donors, are most efficiently screened and identified by red cell genotyping. In transfused patients with challenging serologic reactivity, antibodies are more reliably identified when molecular typing information is available. Red cell genotyping of both donors and patients augments the selection of blood components. This technology, serving at the core of a real-time database inventory, is resulting in blood supply efficiencies. However, there is limited published evidence on the extent to which red cell genotyping has translated into improved clinical outcomes. Red cell alloimmunized patients may benefit the most in enhanced safety. For patients with antibodies to high-prevalence antigens, other than Rh, blood centers realized supply-chain efficiencies in the past decade. Prospective clinical trials and cost-effectiveness studies would contribute to further clarifying the optimal role of molecular testing in providing transfusion support for patients with hematologic diseases.


Assuntos
Transfusão de Eritrócitos/métodos , Genômica/métodos , Humanos , Estudos Prospectivos
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