A Survey of Transfusion Practices in Pediatric Hematopoietic Stem Cell Transplant Patients

Abstract

Until recovery of hematopoiesis, pediatric hematopoietic stem cell transplant (HSCT) patients are dependent on red blood cell and platelet transfusions to avoid the complications associated with anemia and thrombocytopenia, respectively. Despite the fact that these patients are high utilizers of blood components, there are no evidence-based guidelines regarding optimal transfusion practices in this patient population. A web-based survey was designed to examine current transfusion thresholds used by institutions that perform pediatric HSCT. This survey was sent to department directors identified through the Children's Oncology Group directory with a response rate of 69%. The majority of institutions use 8 g/dL as the hemoglobin threshold for red blood cell transfusions (60%), but a significant minority use 7 g/dL (25%). With respect to platelet transfusion thresholds, 47% of respondents report using 20×10/L and 44% use 10×10/L. Respondents were also asked about specific clinical scenarios that would prompt an increase in a patient's threshold. This survey revealed that there is variation in transfusion practices among pediatric HSCT institutions with respect to both baseline transfusion threshold and what prompts an increase in threshold. Future clinical trials are needed to determine optimal transfusion thresholds in pediatric HSCT patients, which can lead to improved standardization in practices.

Complex Transfusion Issues in Pediatric Hematopoietic Stem Cell Transplantation

“…Transfusion thresholds for red blood cells and platelets in the pediatric HSCT patient have largely followed those used in pediatric oncology where hemoglobin levels are kept above 7-8 grams/dL and platelets above 10-20,000/microliter [46,47]. In HSCT for sickle cell disease however, thresholds have been kept higher (9 grams/dL; 50,000 platelets/microliter) based on prior studies showing increased central nervous system complications when using oncology based thresholds [48].…”

2015 proceedings of the National Heart, Lung, and Blood Institute's State of the Science in Transfusion Medicine symposium

“…RBC transfusion has been associated with a greater risk of infection, a common cause of death in patients with hematologic malignancies . Conversely, restrictive transfusion practice could adversely affect their quality of life and functional status, and enhance bleeding in the setting of thrombocytopenia . Multicenter studies of RBC transfusion are feasible using randomized controlled designs in conjunction with clinical trials of chemotherapeutic regimens .…”

Transfusions for anemia in adult and pediatric patients with malignancies

“…Evidence from robust randomized controlled trials is otherwise lacking in children with hematologic malignancies, leading to heterogeneity in practice between different centers and those among patient groups [5,44]. In a survey of pediatric centers from Children's Oncology Group, 60% of centers used a transfusion trigger of hemoglobin 8 g/dl, whereas 25% of centers used 7 g/dl [44]. Clinicians should consider RBC transfusion for children prior to radiation therapy.…”