A prospective randomized trial of a prophylactic platelet transfusion trigger of 10 x 109 per L versus 30 x 109 per L in allogeneic hematopoietic progenitor cell transplant recipients

Update in critical care for the nephrologist: transfusion in nonhemorrhaging critically ill patients

A growing number of guidelines and recommendations advocate a restrictive transfusion strategy. Strong evidence exists that a hemoglobin threshold of less than 7 g/dL conserves resources and may improve outcomes in critically ill patients and that platelet counts greater than 10,000/μL are well tolerated. Patients with coronary artery disease can be safely managed with a restrictive transfusion strategy, utilizing a hemoglobin threshold of less than 7 or 8 g/dL; a threshold of less than 8 g/dL can be applied to patients with acute coronary syndromes. In the absence of coagulopathy with bleeding or high risk for bleeding, plasma transfusion should be withheld. Complications from transfusion are significant and previously under-recognized immunologic complications pose a more serious threat than infections. Erythropoietin and iron administration do not reduce transfusion needs in the critically ill. Interventions to reduce blood loss and educate clinicians are successful in reducing transfusion requirements.

Measuring bleeding as an outcome in clinical trials of prophylactic platelet transfusions

A 12-year-old girl with acute myeloid leukemia has completed her third cycle of chemotherapy and is in the hospital awaiting count recovery. Her platelet count today is 15 000 and, based on your institution's protocol, she should receive a prophylactic platelet transfusion. She has a history of allergic reactions to platelet transfusions and currently has no bleeding symptoms. The patient's mother questions the necessity of today's transfusion and asks what her daughter's risk of bleeding would be if the count is allowed to decrease lower before transfusing. You perform a literature search regarding the risk of bleeding with differing regimens for prophylactic platelet transfusions.

Thrombocytopenia and bleeding in pediatric oncology patients

Prophylactic platelet transfusions are the standard of care for patients with hypoproliferative thrombocytopenia after receiving chemotherapy or radiation for the treatment of malignancy, for BM replacement by leukemia or solid tumor, or in preparation for a hematopoietic stem cell transplantation.1 During this time of thrombocytopenia, these patients may receive both prophylactic platelet transfusions, which are given to prevent potentially life-threatening bleeding when a patient's platelet count drops below a predetermined threshold, and therapeutic platelet transfusions, which are given to treat active or recurrent bleeding. In the 1950s, the invention of the plastic blood bag allowed for the production and storage of platelet concentrates,2 and in the 1960s, it was recognized that prophylactic platelet transfusions effectively reduced hemorrhagic death in patients with newly diagnosed leukemia.3,4 In 1962, Gaydos published the paper that is frequently credited with the inception of the 20 000/μL platelet transfusion threshold.5 Despite a half-century of experience with prophylactic platelet transfusions, there are still insufficient data to provide clinicians with evidence-based guidelines specific to pediatric oncology and hematopoietic stem cell transplantation (HSCT) patients.

Many days at home during neutropenia after allogeneic hematopoietic stem cell transplantation correlates with low incidence of acute graft-versus-host disease

Patients are isolated in the hospital during the neutropenic phase after allogeneic hematopoietic stem cell transplantation. We challenged this by allowing patients to be treated at home. A nurse from the unit visited and checked the patient. One hundred forty-six patients treated at home were compared with matched hospital control subjects. Oral intake was intensified from September 2006 and improved (P = .002). We compared 4 groups: home care and control subjects before and after September 2006. The cumulative incidence of acute graft-versus-host disease (GVHD) of grades II to IV was 15% in the "old" home care group, which was significantly lower than that of 32% to 44% in the other groups (P < .03). Transplantation-related mortality, chronic GVHD, and relapse were similar in the groups. The "new" home care patients spent fewer days at home (P = .002). In multivariate analysis, GVHD of grades 0 to I was associated with home care (hazard ratio [HR], 2.46; P = .02) and with days spent at home (HR, .92; P = .005) but not with oral nutrition (HR, .98; P = .13). Five-year survival was 61% in the home care group as compared with 49% in the control subjects (P = .07). Home care is safe. Home care and many days spent at home were correlated with a low risk of acute GVHD.

The observation of bleeding complications in haemato-oncological patients: stringent watching, relevant reporting

BACKGROUND

The reported percentage of haemato-oncological patients experiencing bleeding complications is highly variable, ranging from 5 to 70%, posing a major problem for comparison of clinical platelet transfusion trials using bleeding complications as a primary endpoint. In a pilot study we assessed the impact of the design of scoring of bleeding on the percentage of patients with WHO grade 2 or higher bleeding grades.

STUDY DESIGN AND METHODS

We performed a prospective, observational study using a rigorous bleeding observation system in thrombocytopenic patients with haemato-oncological disorders. Endpoints of the study were the percentage of patients and days with bleeding WHO grade ≥ 2 comparing designs in which skin bleeding represent a continuation of a previous bleed or a new bleed.

RESULTS

In four participating hospitals 64 patients suffering 870 evaluable thrombocytopenic days (platelet count < 80 × 10(9) L(-1)) were included. At least one episode of bleeding grade ≥ 2 occurred in 36 patients (56%). Most grade 2 bleeding complications occurred mucocutaneously. The percentage of days with bleeding of grade ≥ 2 was 16% but decreases to 8% when only newly developed skin bleeding was included.

CONCLUSION

Rigorous daily observation results in a bleeding incidence that is comparable to recent reportings applying the same method. The results of this study show that censoring for stable skin bleeding has a profound effect on bleeding incidence per day. The clinical relevance of rigorous or clinically judged bleeding scores as an endpoint remains to be defined.

An evidence-based threshold for thrombocytopenia associated with clinically significant bleeding in pediatric intensive care unit patients

OBJECTIVE

To determine the epidemiology and identify the risk factors for clinically significant bleeding in the pediatric intensive care unit.

DESIGN

A retrospective cohort study over 6 months with up to 7 days of observation for each patient.

SETTING

The pediatric intensive care unit in a tertiary care children's hospital.

PATIENTS

Three hundred twenty-six consecutive patients admitted to the pediatric intensive care unit during the study period, with 214 eligible for inclusion.

MEASUREMENTS AND MAIN RESULTS

Clinically significant bleeding, defined using a composite of outcomes. Clinically significant bleeding occurred in 19 patients (8.9%). Recursive partitioning identified a platelet count <100 × 10/L as being associated with clinically significant bleeding. Other factors associated with increased risk included mechanical ventilation, antibiotic and antacid medications, the performance of multiple procedures, and cardiac surgery. Episodes of clinically significant bleeding were observed at a median of 9.8 hrs after admission.

CONCLUSIONS

Clinically significant bleeding is a more common complication for pediatric intensive care unit patients than has been previously reported. The evidence-based threshold for thrombocytopenia identified as a risk factor should be further investigated in a prospective study.

Platelet transfusion threshold in patients with upper gastrointestinal bleeding: a systematic review

BACKGROUND

There exists uncertainty as to the optimal platelet values when managing patients with nonvariceal upper gastrointestinal (GI) bleeding. GOALS AND STUDY: A systematic review was carried out to determine the optimal approach when managing patients with thrombocytopenia in the setting of nonvariceal upper GI bleeding.

RESULTS

Eighteen of 803 potential articles were selected and reviewed, including 4 randomized controlled trials and 6 cohort studies. The only empirical clinical data available pertained to the management of hematology or oncology patients. There was no high-level evidence that determined the proper threshold of platelet transfusion specifically in GI bleeding. We were, therefore, limited to include principally consensus opinions, recommendations, and guidelines for platelet transfusion trigger as they apply to the treatment (including prophylaxis) of bleeding in general, with a paucity of data addressing major bleeding, let alone bleeding from a gastroenterologic origin. Randomized clinical trials were individually underpowered in allowing definitive conclusions, even though resulting recommendations were supported by similarly underpowered retrospective and prospective observational studies.

CONCLUSIONS

There exist a paucity of data to recommend optimal therapeutic platelet count targets in patients with active GI bleeding. Based principally on expert opinion recommendations, we propose a count of 50×10/L. Some professional associations have suggested in very specific clinical settings (postcardiopulmonary bypass surgery or central nervous system trauma) a higher value of up to 100×10/L. Properly designed randomized trials are required to more precisely address this important clinical question.

The influence of bleeding on trigger changes for platelet transfusion in patients with chemotherapy-induced thrombocytopenia

BACKGROUND

For patients with thrombocytopenia without bleeding risk factors, a platelet transfusion trigger of 10 × 10(9) /L is recommended. No studies have evaluated the clinicians' decision-making process leading to trigger changes.

STUDY DESIGN AND METHODS

We report on the evaluation of trigger changes and the relation with bleeding. Eighty patients previously enrolled in the SPRINT trial represent the patient population for the current analysis.

RESULTS

Seventy-four patients had a starting trigger of 10 × 10(9) /L. Only a minority of patients treated with chemotherapy alone (3/12, 25%) and autologous transplant (6/15, 40%) had a change in their trigger in contrast to the majority of allogeneic transplant (37/47, 79%; p = 0.001 and p = 0.009, respectively, when compared to allogeneic transplant group). Bleeding was the main reason reported by clinicians for a trigger change, but the occurrence of significant bleeding (Grade 2-4) was similar in patients with or without a trigger change (51 and 54%, p = 1.00). Clinicians were influenced by the bleeding system: grade 1 mucocutaneous bleeding leading to a trigger change was overrepresented (71% of cases), as was grade 2 genitourinary bleeding not leading to a trigger change (57% of cases).

CONCLUSION

A universal trigger of 10 × 10(9) /L may not be maintained in a diverse population of patients with their respective bleeding risk factors. Because the trigger is changed often, it may not be as effective as previously believed.

Prophylactic platelet transfusion for prevention of bleeding in patients with haematological disorders after chemotherapy and stem cell transplantation

BACKGROUND

Platelet transfusions are used in modern clinical practice to prevent and treat bleeding in thrombocytopenic patients with bone marrow failure. Although considerable advances have been made in platelet transfusion therapy in the last 40 years, some areas continue to provoke debate especially concerning the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding.

OBJECTIVES

To determine the most effective use of platelet transfusion for the prevention of bleeding in patients with haematological disorders undergoing chemotherapy or stem cell transplantation.

SEARCH METHODS

This is an update of a Cochrane review first published in 2004. We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2011), MEDLINE (1950 to Nov 2011), EMBASE (1980 to Nov 2011) and CINAHL (1982 to Nov 2011), using adaptations of the Cochrane RCT search filter, the UKBTS/SRI Transfusion Evidence Library, and ongoing trial databases to 10 November 2011.

SELECTION CRITERIA

RCTs involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in patients with haematological disorders. Four different types of prophylactic platelet transfusion trial were included.

DATA COLLECTION AND ANALYSIS

In the original review one author initially screened all electronically derived citations and abstracts of papers, identified by the review search strategy, for relevancy. Two authors performed this task in the updated review. Two authors independently assessed the full text of all potentially relevant trials for eligibility. Two authors completed data extraction independently. We requested missing data from the original investigators as appropriate.

MAIN RESULTS

There were 18 trials that were eligible for inclusion, five of these were still ongoing.Thirteen completed published trials (2331 participants) were included for analysis in the review. The original review contained nine trials (718 participants). This updated review includes six new trials (1818 participants).Two trials (205 participants) in the original review are now excluded because fewer than 80% of participants had a haematological disorder.The four different types of prophylactic platelet transfusion trial, that were the focus of this review, were included within these thirteen trials.Three trials compared prophylactic platelet transfusions versus therapeutic-only platelet transfusions. There was no statistical difference between the number of participants with clinically significant bleeding in the therapeutic and prophylactic arms but the confidence interval was wide (RR 1.66; 95% CI 0.9 to 3.04).The time taken for a clinically significant bleed to occur was longer in the prophylactic platelet transfusion arm. There was a clear reduction in platelet transfusion usage in the therapeutic arm. There was no statistical difference between the number of participants in the therapeutic and prophylactic arms with platelet refractoriness, the only adverse event reported.Three trials compared different platelet count thresholds to trigger administration of prophylactic platelet transfusions. No statistical difference was seen in the number of participants with clinically significant bleeding (RR 1.35; 95% CI 0.95 to 1.9), however, this type of bleeding occurred on fewer days in the group of patients transfused at a higher platelet count threshold (RR 1.72; 95% CI 1.33 to 2.22).The lack of a difference seen for the number of participants with clinically significant bleeding may be due to the studies, in combination, having insufficient power to demonstrate a difference, or due to masking of the effect by a higher number of protocol violations in the groups of patients with a lower platelet count threshold. Using a lower platelet count threshold led to a significant reduction in the number of platelet transfusions used. There were no statistical differences in the number of adverse events reported between the two groups.Six trials compared different doses of prophylactic platelet transfusions. There was no evidence to suggest that using a lower platelet transfusion dose increased: the number of participants with clinically significant (WHO grade 2 or above) (RR 1.02; 95% CI 0.93 to 1.11), or life-threatening (WHO grade 4) bleeding (RR 1.87; 95% CI 0.86 to 4.08). A higher platelet transfusion dose led to a reduction in the number of platelet transfusion episodes, but an increase in total platelet utilisation. Only one adverse event, wheezing after transfusion, had a significantly higher incidence when standard and high dose transfusions were compared but this difference was not seen when low dose and high dose transfusions were compared. It is therefore likely to be a type I error (false positive).One small trial compared prophylactic platelet transfusions versus platelet-poor plasma. The risk of a significant bleed was decreased in the prophylactic platelet transfusion arm (RR 0.47; 95% CI 0.23 to 0.95) and this was statistically significant.All studies had threats to validity; the majority of these were due to methodology of the studies not being described in adequate detail.Although it was not the main focus of the review, it was interesting to note that in one of the pre-specified sub-group analyses (treatment type) two studies showed that patients receiving an autologous transplant have a lower risk of bleeding than patients receiving intensive chemotherapy or an allogeneic transplant (RR 0.73, 95% CI 0.65 to 0.82).

AUTHORS' CONCLUSIONS

These conclusions refer to the four different types of platelet transfusion trial separately. Firstly, there is no evidence that a prophylactic platelet transfusion policy prevents bleeding. Two large trials comparing a therapeutic versus prophylactic platelet transfusion strategy, that have not yet been published, should provide important new data on this comparison. Secondly, there is no evidence, at the moment, to suggest a change from the current practice of using a platelet count of 10 x 10(9)/L. However, the evidence for a platelet count threshold of 10 x 10(9)/L being equivalent to 20 x 10(9)/L is not as definitive as it would first appear and further research is required. Thirdly, platelet dose does not affect the number of patients with significant bleeding, but whether it affects number of days each patient bleeds for is as yet undetermined. There is no evidence that platelet dose affects the incidence of WHO grade 4 bleeding.Prophylactic platelet transfusions were more effective than platelet-poor plasma at preventing bleeding.

Current practice and future directions for optimization of platelet transfusions in patients with severe therapy-induced cytopenia

Platelet transfusions are mainly used for patients with thrombocytopenia due to bone marrow failure, especially cancer patients developing severe chemotherapy-induced thrombocytopenia (e.g. patients with acute leukemia or other hematologic malignancies). A prophylactic transfusion strategy is now generally accepted in developed countries. Some clinical data, however, support the use of a therapeutic transfusion strategy at least for certain subsets of these patients. Several methodological approaches can then be used to evaluate the outcome of platelet transfusions, including peripheral blood platelet increments and bleeding assessments. Several factors will influence the efficiency of platelet transfusions; fever and ongoing hemorrhage are among the most important patient-dependent factors, but the number and quality of the transfused platelets are also important. The quality of transfused platelets can be evaluated by analyzing platelet activation, metabolism or senescence/apoptosis. Only evaluation of metabolism is included in international guidelines, but high-throughput methods for evaluation of activation and senescence/apoptosis are available and should be incorporated into routine clinical practice if future studies demonstrate that they reflect clinically relevant platelet characteristics. Finally, platelet transfusions have additional biological effects that may cause immunomodulation or altered angioregulation; at present it is not known whether these effects will influence the long-time prognosis of cancer patients. Thus, several questions with regard to the optimal use of platelet transfusions in cancer patients still need to be answered.

Platelet and red blood cell utilization and transfusion independence in umbilical cord blood and allogeneic peripheral blood hematopoietic cell transplants

Allogeneic hematopoietic cell transplantation (HCT) recipients have substantial transfusion requirements. Factors associated with increased transfusions and the extent of blood product use in umbilical cord blood (UCB) recipients are uncertain. We reviewed blood product use in 229 consecutive adult recipients of allogeneic HCT at the University of Minnesota: 147 with leukemia, 82 lymphoma or myeloma; 58% received unrelated UCB and 43% sibling donor peripheral blood stem cell (PBSC) grafts. Although neutrophil recovery was prompt (UCB median 17, range: 2-45 days, and PBSC 14, range: 3-34 days), only 135 of 229 (59% cumulative incidence) achieved red blood cell (RBC) independence and 157 (69%) achieved platelet independence by 6 months. Time to platelet independence was prolonged in UCB recipients (median UCB 41 versus PBSC 14 days) and in patients who had received a prior transplant (median 48 versus 32 days). Patients who received UCB grafts required more RBC through day 60 post-HCT (mean UCB 7.8 (95% confidence interval [CI] 6.7-8.9) versus PBSC 5.2 (3.7-6.7) transfusions, P = .04), and more platelet transfusions (mean 25.2 (95% CI 22.1-28.2) versus 12.9 (9.4-16.4), P < .01) compared to PBSC recipients. Patients receiving myeloablative (MA) conditioning required more RBC and platelet transfusions during the first 2 months post-HCT compared to reduced-intensity conditioning (RIC) (7.4 versus 6.2, P = .30 for RBC; 23.2 versus 17.5, P = .07 for platelets). Despite prompt neutrophil engraftment, UCB recipients had delayed platelet recovery as well as more prolonged and costly blood product requirements. Enhanced approaches to accelerate multilineage engraftment could limit the transfusion-associated morbidity and costs accompanying UCB allotransplantation.

Immunohematopoietic stem cell transplantation in Cape Town: a ten-year outcome analysis in adults

BACKGROUND AND OBJECTIVES

Immunohematopoietic stem cell transplantation has curative potential in selected hematologic disorders. Stem cell transplantation was introduced into South Africa in 1970 as a structured experimental and clinical program. In this report, we summarize the demography and outcome by disease category, gender, and type of procedure in patients older than 18 years of age who were seen from April 1995 to December 2002.

PATIENTS AND METHODS

This retrospective analysis included 247 individuals over 18 years of age for whom complete data were available. These patients received grafts mostly from peripheral blood with the appropriate stem cell population recovered by apheresis.

RESULTS

Patient ages ranged from 20 to 65 years with a median age of 42 years. There were 101 females and 146 males. There were no withdrawals and 63% survived to the end of the study. At 96 months of follow-up, a stable plateau was reached for each disease category. Median survival was 3.3 years (n=6, 14.6%) for acute lymphoblastic anemia, 3.1 years (n=44, 18%) for acute myeloid leukemia, 2.8 years (n=47, 19%) for chronic granulocytic leukemia, 2.8 years (n=71, 29%) for lymphoma, 1.5 years (n=23, 9%) for myeloma, 1.43 years (n=10, 4%) for aplasia, and 1.4 years (n=38, 15%) for a miscellaneous group comprising less than 10 examples each. Multivariate analysis showed that only diagnosis and age had a significant impact on survival, but these two variables might be interrelated. There was no significant difference in outcome by source of graft.

CONCLUSION

The results confirm that procedures carried out in a properly constituted and dedicated unit, which meets established criteria and strictly observes treatment protocols, generate results comparable to those in a First World referral center. Low rates of transplant-related mortality, rejection and graft-versus-host disease are confirmed, but the benefits cannot be extrapolated outside of academically oriented and supervised facilities.

A systematic assessment of the quality of reporting for platelet transfusion studies

BACKGROUND

As evidence-based medicine assumes increasing importance, there is a need for high-quality reporting of clinical studies. A recent review of clinical platelet (PLT) studies indicated variability in reporting. We undertook a critical analysis of PLT transfusion studies to determine the quality of reporting.

STUDY DESIGN AND METHODS

A systematic MEDLINE search for clinical studies of PLT transfusion was performed to identify articles. Relevant observational studies (OBS) were critiqued using the STROBE checklist and randomized controlled clinical trials (RCTs) using the CONSORT checklist. Studies were further evaluated with a PLT-specific checklist developed by the authors. Observations were analyzed descriptively and using Pareto analysis.

RESULTS

A total of 772 articles were identified by the search. Eighty-six articles (23 RCTs and 63 OBS) met eligibility criteria. All RCTs, and a similar number of OBS (24), were randomly selected for analysis. Studies reported the scientific background and rationale, key results, and outcomes. OBS frequently did not consider bias and confounders. RCTs frequently did not explain bias, interim analyses, stopping rules, success of blinding, or weaknesses of multiple analyses. The PLT-specific critique found many studies adequately reported basics of the PLT product, PLT increment, and transfusion reactions. Studies frequently failed to report specific details of PLT compatibility, details of product preparation, and use of other blood products.

CONCLUSION

Recently published articles of clinical PLT transfusion share common strengths and weaknesses. The quality of reporting may be improved by providing guidelines to authors and journal editors that list the essential elements of a well-reported clinical study of PLT transfusion.

Role of transfusion in stem cell transplantation: a freedom-from-transfusion (FFT), cost and survival analysis

BACKGROUND

Transfusion of blood products is often necessary for patients undergoing stem cell transplantation (SCT). The need for red cell and platelet transfusion may vary significantly depending on the type of transplantation and underlying disease.

METHODS

In an attempt to evaluate the need and volume of transfusions in patients undergoing SCT at University of Kansas Medical Center, the authors retrospectively evaluated the transfusion data of all patients who received SCT between 2000 and 2005.

RESULTS

A total of 138 (90%) out of 154 patients undergoing autologous SCT and 24 (43%) out of 56 patients with allogeneic SCT exhibited total hematopoietic engraftment and freedom from transfusion (FFT). Time to achieve FFT (median; range) for RBC units for autologous SCT (12; 0-183) was significantly shorter compared with allogeneic SCT (16.5; 0-373). Number of RBC units (median; range) transfused were significantly less in patients undergoing autologous SCT (4; 0-26) compared to patients undergoing allogeneic SCT (6.5; 0-54). The median cost of transfusion was significantly higher in patients undergoing allogeneic SCT (red cell: $2,015; platelet: $4,480) compared to patients undergoing autologous SCT (red cell: $1,240; platelet: $2,520). The authors recognize that this was a retrospective single-center study and practice guidelines may vary from center to center.

CONCLUSION

Authors conclude that transfusion of blood products is an expensive but integral part of SCT, more so for allogeneic SCT than for patients undergoing autologous SCT. Total FFT is a desirable long-term goal of successful marrow transplantation.

Utilization of blood and components in a tertiary care hospital

PURPOSE

Blood transfusion is an important part of patient management. Indications for blood use must be clear in the mind of ordering clinicians, to avoid its misuse and also to avoid unnecessary exposure of the patient to donor blood antigens, adverse reactions and transfusion transmissible diseases.

METHODS

In a retrospective pilot study, details of whole blood and components transfused were noted and correlated with the patient's diagnosis and indications for transfusion, during 1 month.

RESULTS

The blood units supplied were 720. Whole blood was the most utilized product; followed by packed red blood cells. Supply of blood was maximum to the surgical wards. The patients of trauma followed by malignancy and surgery required whole blood mostly. Anemia was the most common indication for blood products.

CONCLUSIONS

Periodic review of blood component usage is very important to assess the blood utilization pattern in any hospital.

Gastrointestinal bleeding in the cancer patient

Gastrointestinal bleeding is a common occurrence in patients with cancer and is a frequent indicator of a gastrointestinal malignancy. Rapid evaluation and treatment is key for the hemodynamically unstable patient. Endoscopy remains the cornerstone of diagnosis and management for cancer patients with gastrointestinal bleeding. The emergency physician should also be aware of other diagnostic and treatment modalities that may be needed to take care of these patients.

A review of transfusion practice before, during, and after hematopoietic progenitor cell transplantation

The increased use of hematopoietic progenitor cell (HPC) transplantation has implications and consequences for transfusion services: not only in hospitals where HPC transplantations are performed, but also in hospitals that do not perform HPC transplantations but manage patients before or after transplantation. Candidates for HPC transplantation have specific and specialized transfusion requirements before, during, and after transplantation that are necessary to avert the adverse consequences of alloimmunization to human leukocyte antigens, immunohematologic consequences of ABO-mismatched transplantations, or immunosuppression. Decisions concerning blood transfusions during any of these times may compromise the outcome of an otherwise successful transplantation. Years after an HPC transplantation, and even during clinical remission, recipients may continue to be immunosuppressed and may have critically important, special transfusion requirements. Without a thorough understanding of these special requirements, provision of compatible blood components may be delayed and often urgent transfusion needs prohibit appropriate consultation with the patient's transplantation specialist. To optimize the relevance of issues and communication between clinical hematologists, transplantation physicians, and transfusion medicine physicians, the data and opinions presented in this review are organized by sequence of patient presentation, namely, before, during, and after transplantation.

Consensus and controversies in platelet transfusion: trigger for indication, and platelet dose

Platelet transfusion is about to commemorate its 50th year since its introduction in therapeutics. It is then surprising to see, that in spite of reaching this respectful age, we have not been able to definitely establish all the aspects related to its clinical use. Some of these facets are platelet transfusion threshold and the platelet dose to administer. Historically, two different transfusion triggers have been used for prophylactic and therapeutic platelet transfusions. For prophylactic platelet transfusion an increasing body of evidences suggests that a transfusion trigger of 10 x 10(9) per liter is appropriate for most clinical settings. In contrast, evidence for supporting a certain therapeutic transfusion trigger is lacking. Nevertheless, there is consensus that the platelet count should not be allowed to fall below 50 x 10(9) per liter in patients with acute bleeding. Another important aspect still pending of clear definition is the issue of the platelet dose to be transfused. It has been addressed by some small studies but a definite answer to this important clinical issue is, at least so far, still pending. The results of two ongoing trials, one sponsored by NIH through the Clinical Trials Network in Transfusion Medicine and Hemostasis and the other promoted by the BEST Collaborative Group are expected to help us to clearly defining the more effective and efficient way to transfuse platelet concentrates.

A study of the agreement between patient self-assessment and study personnel assessment of bleeding symptoms

BACKGROUND

Clinical trials investigating new platelet transfusion therapies frequently require the assessment of bleeding for the study outcome. These assessments are commonly performed by study personnel and can be time-consuming. The purpose of this study was to assess whether patients were able to reliably assess their bleeding status on a daily basis.

STUDY DESIGN AND METHODS

Patients admitted to hospital to receive chemotherapy for acute leukemia or to undergo allogeneic peripheral blood progenitor cell transplant were included. Patients were given an introduction to a form for documenting the occurrence of 16 bleeding symptoms. Patients completed this form and were examined daily by a study assessor. A weekly health record review was also performed by a study assessor. The agreement between raters was determined by calculating the raw agreement, chance-corrected agreement, and chance-independent agreement.

RESULTS

Thirty-five patients completed 458 assessment forms that were paired with 559 forms completed by a study assessor with 450 matched forms available for analysis (mean, 12.86 per patient). Agreement for most individual bleeding symptoms was high. Thirteen items had agreement greater than 90 percent and all items had agreement greater than 77 percent. The lowest agreement was seen for skin symptoms: petechiae (89.2%), purpura (80.9%), and ecchymosis (77.6%). The negative predictive value of patient self-assessment was high (range, 71.1%-100%) whereas the positive predictive value was lower (range, 0%-86.5%).

CONCLUSION

The reliability was very good between patients and study assessors with the patients reporting excellent negative predictive value and variable positive predictive value.

Feasibility and usefulness of self-assessment of bleeding in patients with haematological malignancies, and the association between platelet count and bleeding

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the collection of daily prospective information about bleeding outcomes in patients with thrombocytopenia, including information obtained by patient self-assessment.

MATERIALS AND METHODS

Consecutive patients with haematological malignancies were enrolled in a study of bleeding data collection during the period of thrombocytopenia. A short educational session and information sheet was designed for self-assessment. Platelet counts and all transfusions were recorded daily. Bleeding scores were translated into World Health Organization (WHO) bleeding grades.

RESULTS

Nineteen patients were included in the study. Four-hundred and ten days of thrombocytopenia were eligible for assessment of bleeds. Self-assessment was feasible, as defined by the total proportion of days on which self-assessment was completed (70%, 288 thrombocytopenic days). There was 86% agreement between bleeding data collected by self-assessment and by medical examination using a structured assessment form. Examples of discrepancies included the duration of petechiae/bruises and the reporting of minor bleeding. There was no evidence for an association between patients' morning platelet count and daily WHO bleeding grade. The incidences of WHO grade 1 and grade 2 bleeding on days with platelet counts < or = 10 x 10(9)/l, 11-20 x 10(9)/l, and > 20 x 10(9)/l were similar and did not reveal higher rates of bleeding at lower counts.

CONCLUSIONS

Patient self-assessment can help to support comprehensive daily prospective monitoring of bleeding, specifically facilitating data collection following hospital discharge. The discrepancies between self-assessment and medical examination highlight the need to develop a validated international assessment tool. The association among platelet count, risk of bleeding and role of prophylactic platelet transfusions needs further evaluation in larger prospective trials.