Higher or Lower Hemoglobin Transfusion Thresholds for Preterm Infants

Kirpalani, Haresh; Bell, Edward F.; Hintz, Susan R.; Tan, Sylvia; Schmidt, Barbara; Chaudhary, Aasma S.; Johnson, Karen; Crawford, Margaret; Newman, Jamie; Vohr, Betty R.; Carlo, Waldemar A.; D’Angio, Carl T.; Kennedy, Kathleen A.; Ohls, Robin K.; Poindexter, Brenda B.; Schibler, Kurt; Whyte, Robin; Widness, John A.; Zupancic, John A.F.; Wyckoff, Myra H.; Truog, William E.; Walsh, Michele C.; Chock, Valerie Y.; Laptook, Abbot R.; Sokol, Gregory M.; Yoder, Bradley A.; Patel, Ravi; Cotten, C. Michael; Carmen, Melissa F; Devaskar, Uday; Chawla, Sanjay; Seabrook, Ruth; Higgins, Rosemary D.; Das, Abhik

doi:10.1056/nejmoa2020248

Cited by 170 publications

(202 citation statements)

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“…Similarly, available evidence supports a restrictive RBC transfusion strategy, showing a favorable NDO at school age among preterm infants randomized to lower RBC transfusion thresholds during NICU admission (17,18,53,57,58,61). Apart from one study (60), this also holds true for NDO at 2 years corrected age.…”

Section: Anemia Rbc Transfusions and Neurodevelopmental Outcomementioning

confidence: 82%

“…The association between RBC transfusion strategy and brain injury during NICU admission is still under debate. Most studies observed no difference in presence of brain injury between RBC transfusion strategies (17)(18)(19)55). Conversely, Bell et al (20) reported more infants with severe IVH and PVL following restrictive RBC transfusion thresholds, possibly because of rather low Hb-and Ht-levels in their restrictive RBC transfusion threshold infants compared to mean Hb-and Ht-levels in other study participants (17)(18)(19).…”

Section: Anemia Rbc Transfusions and Brain Injurymentioning

confidence: 97%

“…Focusing only on the RCTs, there were 4 clinical trials comparing liberal and restrictive RBC transfusion strategies in which a total of 2919 children participated. The first by Kirpalani et al was the TOP trial in which they found no differences in NDO at 22-26 months corrected age between preterm infants randomized to either liberal or restrictive transfusion thresholds (17). Another recently published RCT was the ETTNO trial by Franz et al in which NDO was determined at 24 months corrected age in ELBW neonates (18).…”

Section: Anemia Rbc Transfusions and Neurodevelopmental Outcomementioning

confidence: 99%

“…Transfusion thresholds remain controversial as RBC transfusions are associated with increased risk for ischemia-reperfusion damage or oxidative injury potentially resulting in transfusion-associated necrotizing enterocolitis, bronchopulmonary dysplasia and retinopathy of prematurity (1,16). Several studies comparing high (liberal) and low (restrictive) Hb or Ht thresholds for RBC transfusion have been published (17)(18)(19)(20), but controversies about when to transfuse anemic preterm infants still remain (21)(22)(23).…”

Section: Introductionmentioning

confidence: 99%

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Anemia and Red Blood Cell Transfusions, Cerebral Oxygenation, Brain Injury and Development, and Neurodevelopmental Outcome in Preterm Infants: A Systematic Review

et al. 2021

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Background: Anemia remains a common comorbidity of preterm infants in the neonatal intensive care unit (NICU). Left untreated, severe anemia may adversely affect organ function due to inadequate oxygen supply to meet oxygen requirements, resulting in hypoxic tissue injury, including cerebral tissue. To prevent hypoxic tissue injury, anemia is generally treated with packed red blood cell (RBC) transfusions. Previously published data raise concerns about the impact of anemia on cerebral oxygen delivery and, therefore, on neurodevelopmental outcome (NDO).Objective: To provide a systematic overview of the impact of anemia and RBC transfusions during NICU admission on cerebral oxygenation, measured using near-infrared spectroscopy (NIRS), brain injury and development, and NDO in preterm infants.Data Sources: PubMed, Embase, reference lists.Study Selection: We conducted 3 different searches for English literature between 2000 and 2020; 1 for anemia, RBC transfusions, and cerebral oxygenation, 1 for anemia, RBC transfusions, and brain injury and development, and 1 for anemia, RBC transfusions, and NDO.Data Extraction: Two authors independently screened sources and extracted data. Quality of case-control studies or cohort studies, and RCTs was assessed using either the Newcastle-Ottawa Quality Assessment Scale or the Van Tulder Scale, respectively.Results: Anemia results in decreased oxygen-carrying capacity, worsening the burden of cerebral hypoxia in preterm infants. RBC transfusions increase cerebral oxygenation. Improved brain development may be supported by avoidance of cerebral hypoxia, although restrictive RBC transfusion strategies were associated with better long-term neurodevelopmental outcomes.Conclusions: This review demonstrated that anemia and RBC transfusions were associated with cerebral oxygenation, brain injury and development and NDO in preterm infants. Individualized care regarding RBC transfusions during NICU admission, with attention to cerebral tissue oxygen saturation, seems reasonable and needs further investigation to improve both short-term effects and long-term neurodevelopment of preterm infants.

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Section: Anemia Rbc Transfusions and Neurodevelopmental Outcomementioning

confidence: 82%

Section: Anemia Rbc Transfusions and Brain Injurymentioning

confidence: 97%

Section: Anemia Rbc Transfusions and Neurodevelopmental Outcomementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Anemia and Red Blood Cell Transfusions, Cerebral Oxygenation, Brain Injury and Development, and Neurodevelopmental Outcome in Preterm Infants: A Systematic Review

et al. 2021

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“…While evidence from studies of adult patients cannot be directly extrapolated to pediatric cases, guidelines for pediatric transfusion point toward using a restrictive transfusion approach. 20 Indeed, among extremely low-birthweight infants, a liberal blood transfusion strategy did not reduce the likelihood of death or disability at 24 months compared with a restrictive strategy, as shown by Franz 21 and Kirpalani 22 in the trial Registration ClinicalTrials.gov Identifier: NCT01393496 (ETTNO) and trial ClinicalTrials. gov Identifier: NCT01702805 (TOP) trials, respectively.…”

mentioning

confidence: 95%

Hyperkalemia: The Trojan horse of pediatric transfusion?

Romón

Cortés

2021

Transfusion

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Association of Blood Donor Sex and Age With Outcomes in Very Low-Birth-Weight Infants Receiving Blood Transfusion

et al. 2021

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IMPORTANCE There are conflicting data on the association between blood donor characteristics and outcomes among patients receiving transfusions.OBJECTIVE To evaluate the association of blood donor sex and age with mortality or serious morbidity in very low-birth-weight (VLBW) infants receiving blood transfusions. DESIGN, SETTING, AND PARTICIPANTSThis is a cohort study using data collected from 3 hospitals in Atlanta, Georgia. VLBW infants (Յ1500 g) who received red blood cell (RBC) transfusion from exclusively male or female donors were enrolled from January 2010 to February 2014. Infants received follow-up until 90 days, hospital discharge, transfer to a non-study-affiliated hospital, or death. Data analysis was performed from July 2019 to December 2020.EXPOSURES Donor sex and mean donor age. MAIN OUTCOMES AND MEASURESThe primary outcome was a composite outcome of death, necrotizing enterocolitis (Bell stage II or higher), retinopathy of prematurity (stage III or higher), or moderate-to-severe bronchopulmonary dysplasia. Modified Poisson regression, with consideration of covariate interactions, was used to estimate the association between donor sex and age with the primary outcome, with adjustment for the total number of transfusions and birth weight. RESULTSIn total, 181 infants were evaluated, with a mean (SD) birth weight of 919 (253) g and mean (SD) gestational age of 27.0 (2.2) weeks; 56 infants (31%) received RBC transfusion from exclusively female donors. The mean (SD) donor age was 46.6 (13.7) years. The primary outcome incidence was 21% (12 of 56 infants) among infants receiving RBCs from exclusively female donors, compared with 45% (56 of 125 infants) among those receiving RBCs from exclusively male donors. Significant interactions were detected between female donor and donor age (P for interaction = .005) and between female donor and number of transfusions (P for interaction < .001). For the typical infant, who received a median (interquartile range) of 2 (1-3) transfusions, RBC transfusion from exclusively female donors, compared with male donors, was associated with a lower risk of the primary outcome (relative risk, 0.29; 95% CI, 0.16-0.54). The protective association between RBC transfusions from female donors, compared with male donors, and the primary outcome increased as the donor age increased, but decreased as the number of transfusions increased. CONCLUSIONS AND RELEVANCEThese findings suggest that RBC transfusion from female donors, particularly older female donors, is associated with a lower risk of death or serious morbidity in VLBW infants receiving transfusion. Larger studies confirming these findings and examining potential mechanisms are warranted.

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Higher or Lower Hemoglobin Transfusion Thresholds for Preterm Infants

Cited by 170 publications

References 37 publications

Anemia and Red Blood Cell Transfusions, Cerebral Oxygenation, Brain Injury and Development, and Neurodevelopmental Outcome in Preterm Infants: A Systematic Review

Anemia and Red Blood Cell Transfusions, Cerebral Oxygenation, Brain Injury and Development, and Neurodevelopmental Outcome in Preterm Infants: A Systematic Review

Hyperkalemia: The Trojan horse of pediatric transfusion?

Association of Blood Donor Sex and Age With Outcomes in Very Low-Birth-Weight Infants Receiving Blood Transfusion

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