Red Blood Cell Transfusions and the Risk of Allosensitization in Patients Awaiting Primary Kidney Transplantation

Leffell, Mary S.; Kim, Deborah; Vega, Renato M.; Zachary, Andrea A.; Petersen, Jeffrey; Hart, John Mason; Rossert, Jérôme; Bradbury, Brian D.

doi:10.1097/01.tp.0000437435.19980.8f

Cited by 70 publications

(55 citation statements)

References 35 publications

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“…This has important implications. Recent evidence has shown that RBC transfusion can cause allosensitization [23,24] , such that the increased use of transfusions could possibly result in increased sensitization in the dialysis population overall [23,25,26] . This is important because sensitized kidney transplant candidates wait longer and their graft survival is shorter should they undergo transplant [27] .…”

Section: Discussionmentioning

confidence: 99%

Trends in Anemia Management Practices in Patients Receiving Hemodialysis and Peritoneal Dialysis: A Retrospective Cohort Analysis

Wetmore¹,

Peng²,

Monda³

et al. 2015

Am J Nephrol

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Background/Aims: Recent changes in clinical practice guidelines and reimbursement policies may have affected the use of anemia-related medications and red blood cell (RBC) transfusions in peritoneal dialysis (PD) and hemodialysis (HD) patients. We sought to compare patterns of erythropoiesis-stimulating agents (ESA) and intravenous (IV) iron use, achieved hemoglobin levels, and RBC transfusion use in PD and HD patients. Methods: In quarterly cohorts of prevalent dialysis patients receiving persistent therapy (>3 months), 2007-2011, with Medicare Parts A and B coverage, we assessed ESA and IV iron use and dose, RBC transfusions, and hemoglobin levels. Quarterly transfusion rates were calculated. Results: Observable PD and HD patients numbered 14,958 and 221,866 in Q1/2007 and 17,842 and 256,942 in Q4/2011. Adjusted ESA use was lower in PD (71.4-80.1%) than in HD (86.9-92.0%) patients, decreasing from 80.1% (Q1/2010) to 71.4% (Q4/2011) in PD patients, and from 92.0 to 86.9% in HD patients. The mean adjusted ESA dose decreased by 67.5% in PD and 58.4% in HD patients. IV iron use tended to increase, peaking at 39.3% for PD (Q3/2011) and 80.5% for HD (Q2/2011) patients. Adjusted mean hemoglobin levels fell from 11.7 to 10.6 mg/dl in PD and from 12.0 to 10.7 mg/dl in HD ESA users; adjusted transfusion rates increased from 2.4 to 3.0 per 100 patient-months in PD and from 2.6 to 3.3 in HD patients. Conclusions: In patients receiving persistent dialysis, dose and frequency of ESA administrations decreased during the period 2007-2011. Mean hemoglobin levels decreased by more than 1 g/dl, while transfusion rates increased by approximately 25%.

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Section: Discussionmentioning

confidence: 99%

Trends in Anemia Management Practices in Patients Receiving Hemodialysis and Peritoneal Dialysis: A Retrospective Cohort Analysis

Wetmore¹,

Peng²,

Monda³

et al. 2015

Am J Nephrol

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“…8, 28 In spite of the consistent finding of an association between mechanical circulatory support and allosensitization, the mechanism of sensitization has not been completely delineated. Transfusion of blood products has previously been associated with allosensitization, 29, 30 but avoidance of transfusing leukofiltered cellular blood products has not been shown to prevent it. 31 Differences in the immunogenicity of the various devices may play a role with more contemporary devices potentially posing a lower risk for allosensitization than earlier iterations of VADs.…”

Section: Discussionmentioning

confidence: 99%

Influence of durable mechanical circulatory support and allosensitization on mortality after heart transplantation

Chiu

Schaffer

Oyer

et al. 2016

The Journal of Heart and Lung Transplantation

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Introduction Allosensitization has been shown to negatively impact post-heart transplant (HTx) survival even with a negative crossmatch. Whether MCS-related allosensitization is associated with worse post-HTx survival remains controversial. Materials and Methods Adult HTx recipients listed in the United Network for Organ Sharing database (7/06–12/12) were identified. Multivariate Cox regression assessed the effect of allosensitization on survival. Propensity matching was performed to compare allosensitized and non-sensitized patients. Kaplan-Meier survival analysis compared matched and unmatched patients in both the MCS and medically managed cohorts. Results We identified 11,840 HTx recipients, of whom 4,167 had MCS. MCS was associated with allosensitization in multivariate logistic regression. Each different MCS devices was associated with worse post-HTx survival in multivariate Cox regression. Allosensitization did not predict post-HTx mortality in MCS patients, HR: 1.07 (0.89–1.28), P=0.48. Among patients without MCS, allosensitization was associated with post-HTx mortality, HR: 1.19 (1.03–1.39), P=0.02. Kaplan-Meier analysis revealed equivalent survival in unmatched and matched cohorts when comparing MCS patients who were allosensitized and non-sensitized MCS patients. Among non-MCS patients, allosensitization was associated with worse survival in both unmatched and matched analysis. Conclusions MCS was associated with allosensitization. For MCS patients, allosensitization did not independently predict worse post-HTx outcome. Among non-MCS patients, allosensitization was associated with worse post-HTx survival. Allosensitization appears to be a heterogeneous process influenced by presence of MCS.

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“…Our study is also novel in its evaluation of the potential adverse consequences of withholding intravenous iron during active infection, particularly the possibility of increasing the rate of RBC transfusion, which may also pose risk for infection (20,21) and can lead to sensitization among patients awaiting kidney transplants (22), or higher use of ESAs. We found that transfusion was a rare event during hospitalization for infection, and we did not observe a higher risk of transfusion among patients who did not receive intravenous iron during hospital admission.…”

Section: Discussionmentioning

confidence: 99%

Receipt of Intravenous Iron and Clinical Outcomes among Hemodialysis Patients Hospitalized for Infection

Ishida

Marafino

McCulloch

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives Anemia guidelines for CKD recommend withholding intravenous iron in the setting of active infection, although no data specifically support this recommendation. This study aimed to examine the association between intravenous iron and clinical outcomes among hemodialysis patients hospitalized for infection.Design, setting, participants, & measurements This was a retrospective observational cohort study using data from the US Renal Data System of 22,820 adult Medicare beneficiaries on in-center hemodialysis who had received intravenous iron in the 14 days preceding their first hospitalization for bacterial infection in 2010. In multivariable analyses, the association between receipt of intravenous iron at any point from the day of hospital admission to discharge and all-cause 30-day mortality, mortality in 2010, length of hospital stay, and readmission for infection or death within 30 days of discharge was evaluated.Results There were 2463 patients (10.8%) who received intravenous iron at any point from the day of admission to discharge. Receipt of intravenous iron was not associated with age, dialysis vintage, or comorbidities. There were 2618 deaths within 30 days of admission and 6921 deaths in 2010 (median follow-up 173 days; 25th and 75th percentiles, 78-271 days). The median length of stay was 7 days (25th and 75th percentiles, 5-12 days). Receipt of intravenous iron was not associated with higher 30-day mortality (odds ratio, 0.86; 95% confidence interval [95% CI], 0.74 to 1.00), higher mortality in 2010 (hazard ratio, 0.92; 95% CI, 0.85 to 1.00), longer mean length of stay (10.1 days [95% CI, 9.7 to 10.5] versus 10.5 days [95% CI, 10.3 to 10.7]; P=0.05), or readmission for infection or death within 30 days of discharge (odds ratio, 1.08; 95% CI, 0.96 to 1.22) compared with no receipt of intravenous iron.Conclusions This analysis does not support withholding intravenous iron upon admission for bacterial infection in hemodialysis patients, although clinical trials are required to make definitive recommendations.

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Red Blood Cell Transfusions and the Risk of Allosensitization in Patients Awaiting Primary Kidney Transplantation

Abstract: Sensitization from transfusion can occur in up to 20% of transplant candidates, resulting in higher antibody levels and CPRA values that adversely impact access to transplantation. These results support transfusion avoidance whenever possible.

Cited by 70 publications

References 35 publications

Trends in Anemia Management Practices in Patients Receiving Hemodialysis and Peritoneal Dialysis: A Retrospective Cohort Analysis

Trends in Anemia Management Practices in Patients Receiving Hemodialysis and Peritoneal Dialysis: A Retrospective Cohort Analysis

Influence of durable mechanical circulatory support and allosensitization on mortality after heart transplantation

Receipt of Intravenous Iron and Clinical Outcomes among Hemodialysis Patients Hospitalized for Infection

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