Transfusions for anemia in adult and pediatric patients with malignancies

Abstract

Anemia is present in over two-thirds of patients with malignant hematological disorders. The etiology of anemia predominates from ineffective erythropoiesis from marrow infiltration, cytokine related suppression, erythropoietin suppression, and vitamin deficiency; ineffective erythropoiesis is further exacerbated by accelerated clearance due to antibody mediated hemolysis and thrombotic microangiopathy. As the anemia is chronic in nature, symptoms are generally well tolerated and often non-specific. Transfusion of red blood cells (RBCs) is a balance between providing benefit for patients while avoiding risks of transfusion. Conservative/restrictive RBC transfusion practices have shown equivalent patient outcomes compared to liberal transfusion practices, and meta-analysis has shown improved in-hospital mortality, reduced cardiac events, re-bleeding, and bacterial infections. The implications for a lower threshold for transfusion in patients with malignancies are therefore increasingly being scrutinized. Alternative management strategies for anemia with IV iron and erythropoietin stimulating agents (ESAs) should be considered in the appropriate settings.

Systematic reviews of guidelines and studies for single versus multiple unit transfusion strategies

“…Both articles related to transfusion in adults without recommendations for any specific patient population. Patient populations in all articles in which single‐unit transfusion strategies were recommended in articles included the following: critical illness, autoimmune hemolytic anemia, the perioperative setting, inflammatory bowel disease, malignancies, and pediatrics . All articles that recommended either a single‐ or a multiple‐unit transfusion strategy either did not have literature to support the recommendation or cited studies supporting restrictive transfusion strategies.…”

“…All articles that recommended either a single‐ or a multiple‐unit transfusion strategy either did not have literature to support the recommendation or cited studies supporting restrictive transfusion strategies. The earliest article to recommend a single‐unit transfusion strategy was recommended in 1992; 9 (34.6%) of these articles were published before 2010, and the remainder (17 [65.4%]) were published in 2010 or after . In general, the number of articles recommending single‐unit transfusions has increased over time (Fig.…”

“…These guidelines encompassed adult patients without any patient population specified (seven guidelines), adult patients with critical illness (two guidelines), adult perioperative patients (two guidelines), peripartum patients (one guideline), and pediatric patients (one guideline) . Of the 83 review articles, only 14 (16.9%) contained a recommendation for a single‐ or multiple‐unit transfusion strategy . Of those 14 articles, 13 (92.9%) recommended transfusing one unit at a time .…”

“…Of the 83 review articles, only 14 (16.9%) contained a recommendation for a single‐ or multiple‐unit transfusion strategy . Of those 14 articles, 13 (92.9%) recommended transfusing one unit at a time . In articles relating to pediatrics, 6 were guidelines, 2 were systematic reviews, and 15 were review articles pertaining to RBC transfusion.…”

Blood Transfusion Therapy

“…The authors have previously reviewed blood transfusion practices, 3,5,6 and herein they provide an updated review of RBC therapy in adult and pediatric patients. The article summarizes current blood risks and indications for RBC transfusion.…”