Effects of ABO Matching of Platelet Transfusions in Critically Ill Children

Transfusion outcomes and clinical safety of ABO-nonidentical platelets transfusion: A systematic review and meta-analysis

BACKGROUND

ABO-nonidentical platelets transfusion has been frequently employed to address clinical platelets insufficiencies. The significance of ABO compatibility for platelets transfusion is not clearly defined. This study is aimed to explore the transfusion outcomes and clinical safety of ABO-nonidentical platelets transfusion.

STUDY DESIGN AND METHODS

A systematic articles search was performed for eligible studies published up to November 30, 2023 through the PubMed, Embase, Cochrane library, Chinese National Knowledge Infrastructure database, Wanfang database and SinMed. Meta-analysis Of Observational Studies in Epidemiology study guidelines for observational studies and Newcastle Ottawa bias scale were implemented to assess studies. Meta-analysis was performed using Manager 5.3. This study is registered with PROSPERO, number CRD42023417824.

RESULTS

A total of 11 retrospective cohort studies and 7 prospective cohort studies with a sample size of 104,359 platelets transfusions were included. There was significant difference in transfusion effectiveness between the ABO-identical and ABO-nonidentical platelets transfusions (RR 1.20, 95 % CI 1.11-1.38, P < 0.00001, I2 = 21 %), also the ABO-identical platelets transfusions showed more platelets increment than ABO-nonidentical ones, but it was not statistically significant (MD 0.34, 95 % CI - 0.01 to 0.70, P = 0.06, I2 = 0 %). Allergy and fever occurred more in ABO-nonidentical platelets transfusions in terms of adverse reactions (RR 0.63, 95 % CI 0.41-0.96, P = 0.03, I2 = 0 %; RR 0.59, 95 % CI 0.37-0.94, P = 0.03, I2 = 31 %). When it comes to the mortality, the ABO-identical platelets transfusions did not statistically improve survival in patients who received multiple platelets transfusions (RR 0.77, 95 % CI 0.72-0.83, P = 0.17, I2 = 38 %) and who only received less than 3 transfusions (RR 0.74, 95 % CI 0.52-1.06, P = 0.10, I2 = 47 %) compared with the ABO-nonidentical platelets transfusions.

CONCLUSION

In comparison to ABO-identical platelets transfusions, nonidentical platelets transfusions exhibited lower transfusion efficacy. However, the clinical safety between these two groups was similar, which indicated that ABO-nonidentical transfusions are acceptable, albeit inferior to ABO-identical ones.

Neonatal Intensive Care Unit Patients Receiving More Than 25 Platelet Transfusions

OBJECTIVE

 A few patients in neonatal intensive care units (NICU) receive numerous platelet transfusions. These patients can become refractory, defined as transfusions of ≥10 mL/kg failing to increase the platelet count by at least 5,000/µL. Causes of, and best treatments for, platelet transfusion refractoriness in neonates have not been defined.

STUDY DESIGN

 Multi-NICU multiyear retrospective analysis of neonates receiving >25 platelet transfusions.

RESULTS

 Eight neonates received 29 to 52 platelet transfusions. All eight were blood group O. Five had sepsis, four were very small for gestational age, four had bowel resections, two Noonan syndrome, two had cytomegalovirus infection. All eight had some (19-73%) refractory transfusions. Many (2-69%) of the transfusions were ordered when the platelet count was >50,000/µL. Higher posttransfusion counts occurred after ABO-identical transfusions (p = 0.026). Three of the eight had late NICU deaths related to respiratory failure; all five survivors had severe bronchopulmonary dysplasia requiring tracheostomy for prolonged ventilator management.

CONCLUSION

 Neonates who are high users of platelet transfusions appear to be at high risk for poor outcomes, especially respiratory failure. Future studies will examine whether group O neonates are more likely to develop refractoriness and whether certain neonates would have a higher magnitude of posttransfusion rise if they received ABO-identical donor platelets.

KEY POINTS

· Many of the platelet transfusions given in the NICU are given to a small subset of patients.. · Refractoriness to platelet transfusions is common among these very high recipients.. · Neonates who are high users of platelet transfusions appear to be at high risk for poor outcomes..

Platelet Transfusions in a Multi-NICU Healthcare Organization Before And After Publication of the PlaNeT-2 Clinical Trial

OBJECTIVES

To evaluate whether implementing more restrictive NICU platelet transfusion guidelines following the PlaNeT-2 randomized controlled trial (transfusion threshold changed from 50,000/μL to 25,000/μL for most neonates) was associated with fewer NICU patients receiving a platelet transfusion, without adversely affecting outcomes.

STUDY DESIGN

Multi-NICU retrospective analysis of platelet transfusions, patient characteristics, and outcomes during three years before vs. three years after revising system-wide guidelines.

RESULTS

During the first period, 130 neonates received one or more platelet transfusions; this fell to 106 during the second. The transfusion rate was 15.9/1000 NICU admissions in the first period vs. 12.9 in the second (p=0.106). During the second period, a smaller proportion of transfusions was administered when the platelet count was in the 50,000 - 100,000/μL range (p=0.017), and a larger proportion when it was <25,000/μL (p=0.083). We also saw a fall in the platelet counts that preceded the order for transfusion from 43,100/μL to 38,000/μL (p=0.044). The incidence of adverse outcomes did not change.

CONCLUSIONS

Changing platelet transfusion guidelines in a multi-NICU network to a more restrictive practice was not associated with a significant reduction in number of neonates receiving a platelet transfusion. The guideline implementation was associated with a reduction in the mean platelet count triggering a transfusion. We speculate that further reductions in platelet transfusions can safely occur with additional education and accountability tracking.

How I use platelet transfusions

Platelet transfusions are commonly administered for the prevention or treatment of bleeding in patients with acquired thrombocytopenia across a range of clinical contexts. Recent data, including randomized trials, have highlighted uncertainties in the risk-benefit balance of this therapy, which is the subject of this review. Hemovigilance systems report that platelets are the most frequently implicated component in transfusion reactions. There is considerable variation in platelet count increment after platelet transfusion, and limited evidence of efficacy for clinical outcomes, including prevention of bleeding. Bleeding events commonly occur despite the different policies for platelet transfusion prophylaxis. The underlying mechanisms of harm reported in randomized trials may be related to the role of platelets beyond hemostasis, including mediating inflammation. Research supports the implementation of a restrictive platelet transfusion policy. Research is needed to better understand the impact of platelet donation characteristics on outcomes, and to determine the optimal thresholds for platelet transfusion before invasive procedures or major surgery (eg, laparotomy). Platelet transfusion policies should move toward a risk-adapted approach that does not focus solely on platelet count.

Hemostatic efficacy of pathogen-reduced platelets in children undergoing cardiopulmonary bypass

BACKGROUND

Pediatric patients undergoing cardiopulmonary bypass (CPB) often require blood component transfusions. Pathogen-reduction (PR) of platelets reduces the risk of microbial contamination; however, its effect on hemostatic efficacy in this population is unclear. This study sought to characterize the hemostatic efficacy of PR platelets in children undergoing CPB.

STUDY DESIGN AND METHODS

We performed a retrospective chart review of patients admitted to a pediatric intensive care unit following CPB surgery from 2015 to 2019. Demographic data, validated scoring of repair complexity, products received, and outcomes were compared. The primary outcome was postoperative chest tube bleeding.

RESULTS

A total of 140 patients were enrolled. The majority of surgeries (124/140) were Risk Adjustment for Congenital Heart Surgery (RACHS) 1-3 repairs. Seventy-four percent of patients (104/140) received only standard platelets whereas 26% (36/140) received PR platelets. There were no differences between the groups in the age (p = .90), sex (p = .20) or RACHS score (p = .06). Postoperatively, there was no difference in the median chest tube output for 1 h (p = .27), 2 h (p = .26), 4 h (p = .09), 8 h (p = .16), or for the first 24 h following surgery (p = .23) in patients who received standard versus PR platelets. There was also no difference in receipt of platelets (p = .18), cell saver (p = .79), or cryoprecipitate (p = .28).

CONCLUSION

Patients receiving PR platelets did not have more blood loss or require more transfusions than those who received standard platelets. This suggests that PR platelets may provide acceptable hemostasis with the additional benefits of reduced risk of microbial contamination in pediatric patients undergoing CPB.

What Laboratory Tests and Physiologic Triggers Should Guide the Decision to Administer a Platelet or Plasma Transfusion in Critically Ill Children and What Product Attributes Are Optimal to Guide Specific Product Selection? From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding

OBJECTIVES

To present consensus statements and supporting literature for plasma and platelet product variables and related laboratory testing for transfusions in general critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.

DESIGN

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

SETTING

Not applicable.

PATIENTS

Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for laboratory testing and blood product attributes for platelet and plasma transfusions. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed five expert consensus statements and two recommendations in answer to two questions: what laboratory tests and physiologic triggers should guide the decision to administer a platelet or plasma transfusion in critically ill children; and what product attributes are optimal to guide specific product selection?

CONCLUSIONS

The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program provides some guidance and expert consensus for the laboratory and blood product attributes used for decision-making for plasma and platelet transfusions in critically ill pediatric patients.

Plasma and Platelet Transfusion Strategies in Critically Ill Children With Malignancy, Acute Liver Failure and/or Liver Transplantation, or Sepsis: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding

OBJECTIVES

To present the consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.

DESIGN

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

SETTING

Not applicable.

PATIENTS

Critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of 13 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 12 expert consensus statements.

CONCLUSIONS

In the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program, the current absence of evidence for use of plasma and/or platelet transfusion in critically ill children with malignancy, acute liver disease and/or following liver transplantation, and sepsis means that only expert consensus statements are possible for these areas of practice.

Neonatal Platelet Transfusions: Starting Again

Preterm neonates with severe thrombocytopenia are frequently prescribed prophylactic platelet transfusions despite no evidence of benefit. Neonatal platelet transfusion practice varies, both nationally and internationally. Volumes and rates of transfusion in neonatology are based on historic precedent and lack an evidence base. The etiology of harm from platelet transfusions is poorly understood. Neonates are expected to be the longest surviving recipients of blood produce transfusions, and so avoiding transfusion associated harm is critical in this cohort. This article reviews the evidence for and against platelet transfusion in the neonate and identifies areas of future potential neonatal platelet transfusion research.

Transfusion practices in a large cohort of hospitalized children

BACKGROUND

While previous studies have described the use of blood components in subsets of children, such as the critically ill, little is known about transfusion practices in hospitalized children across all departments and diagnostic categories. We sought to describe the utilization of red blood cell, platelet, plasma, and cryoprecipitate transfusions across hospital settings and diagnostic categories in a large cohort of hospitalized children.

STUDY DESIGN AND METHODS

The public datasets from 11 US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) were accessed. All nonbirth inpatient encounters of children 0-18 years of age from 2013 to 2016 were included.

RESULTS

61,770 inpatient encounters from 41,943 unique patients were analyzed. Nine percent of encounters involved the transfusion of at least one blood component. RBC transfusions were most common (7.5%), followed by platelets (3.9%), plasma (2.5%), and cryoprecipitate (0.9%). Children undergoing cardiopulmonary bypass were most likely to be transfused. For the entire cohort, the median (interquartile range) pretransfusion laboratory values were as follows: hemoglobin, 7.9 g/dl (7.1-10.4 g/dl); platelet count, 27 × 10⁹ cells/L (14-54 × 10⁹ cells/L); and international normalized ratio was 1.6 (1.4-2.0). Recipient age differences were observed in the frequency of RBC irradiation (95% in infants, 67% in children, p < .001) and storage duration of RBC transfusions (median storage duration of 12 [8-17] days in infants and 20 [12-29] days in children, p < .001).

CONCLUSION

Based on a cohort of patients from 2013 to 2016, the transfusion of blood components is relatively common in the care of hospitalized children. The frequency of transfusion across all pediatric hospital settings, especially in children undergoing cardiopulmonary bypass, highlights the opportunities for the development of institutional transfusion guidelines and patient blood management initiatives.

Platelet transfusion practice and platelet refractoriness for a cohort of pediatric oncology patients: A single-center study

BACKGROUND

Platelet transfusions are an essential aspect of supportive care for pediatric oncology patients. Data regarding the frequency of transfusions, pretransfusion thresholds, posttransfusion increments, and rate of platelet transfusion refractoriness (PTR) are lacking.

STUDY OBJECTIVES

(a) describe platelet transfusion practice for children with malignancy; (b) determine the normal platelet increment following platelet transfusion; and (c) assess rate of PTR.

METHODS

Inpatient pediatric oncology patients <18 years old and treated between 2009 and 2013 were identified. Data collected retrospectively included patient demographics, clinical information, laboratory values, and transfusion details.

RESULTS

Three hundred sixty-seven children were included and 144 (39%) received at least one platelet transfusion. Platelets were transfused during 25% of all inpatient admissions. The median number of platelet transfusion for any given inpatient admission was two (interquartile range [IQR]: 1-3). The median pretransfusion platelet count was 16 × 10⁹ /L and posttransfusion increment was 25 × 10⁹ /L. Most (79%) of the time, the pretransfusion platelet count was >10 × 10⁹ /L. Older children who received ABO incompatible platelet transfusions with a longer storage duration were more likely to have a poor platelet response (increment ≤ 10 × 10⁹ /L). The rate of PTR (immune and/or nonimmune) was low (8%; 11/144).

CONCLUSIONS

Practical information to parents and clinicians of newly diagnosed children regarding the likelihood and frequency of platelet transfusions was determined. The rate of PTR was low, supporting the hypothesis that children receiving leukoreduced products are at a low risk of PTR.

Effect of platelet storage duration on clinical outcomes and incremental platelet change in critically ill children

The safety of platelet (PLT) concentrates with longer storage duration has been questioned due to biochemical and functional changes that occur during blood collection and storage. Some studies have suggested that transfusion efficacy is decreased and immune system dysfunction is worsened with increased storage age. We sought to describe the effect of PLT storage age on laboratory and clinical outcomes in critically ill children receiving PLT transfusions.

STUDY DESIGN AND METHODS

We performed a secondary analysis of a prospective, observational point-prevalence study. Children (3 days to 16 years of age) from 82 pediatric intensive care units in 16 countries were enrolled if they received a PLT transfusion during one of the predefined screening weeks. Outcomes (including PLT count increments, organ dysfunction, and transfusion reactions) were evaluated by PLT storage age.

RESULTS

Data from 497 patients were analyzed. The age of the PLT transfusions ranged from 1 to 7 days but the majority were 4 (24%) or 5 (36%) days of age. Nearly two-thirds of PLT concentrates were transfused to prevent bleeding. The indication for transfusion did not differ between storage age groups (P = .610). After patient and product variables were adjusted for, there was no association between storage age and incremental change in total PLT count or organ dysfunction scoring. A significant association between fresher storage age and febrile transfusion reactions (P = .002) was observed.

CONCLUSION

The results in a large, diverse cohort of critically ill children raise questions about the impact of storage age on transfusion and clinical outcomes which require further prospective evaluation.

Neonatal and pediatric platelet transfusions: current concepts and controversies

PURPOSE OF REVIEW

In this review, we focus on three specific concepts related to platelet transfusion in the neonatal and pediatric population: choice of transfusion threshold; use of ABO-mismatched platelets; transfusion of pathogen-reduced or inactivated platelets.

RECENT FINDINGS

Recent trials support the use of lower platelet transfusion thresholds (25 000/μl) in preterm neonates, although data is limited to guide transfusion among more mature neonates. In children, there is low-level evidence as to what the prophylactic platelet transfusion threshold should be in many situations of thrombocytopenia, revealing major variability in platelet transfusion practices. Most pediatric guidelines are extrapolated from adult studies with the most evidence in treatment-associated hypoproliferative thrombocytopenia varying between a platelet transfusion threshold of 10 000/μl to 20 000/μl. Although pathogen-reduced platelets may lower the risks of transfusion-transmitted infection, the effects on platelet refractoriness and transfusion burden in this population warrant additional study.

SUMMARY

Our review highlights recent advances in neonatal and pediatric platelet transfusion and also emphasizes the urgent need for better evidence to guide practice given recent studies showing the potential harms of platelet transfusion, particularly with liberal use.

Pediatric non-red cell blood product transfusion practices: what's the evidence to guide transfusion of the 'yellow' blood products?

PURPOSE OF REVIEW

Research studies pertaining to the management of pediatric non-red cell blood product transfusion is limited. Clinical practices vary within disciplines and regions. Anesthesiologists need evidence-based guidelines to make appropriate and safe decisions regarding transfusion of the 'yellow' blood products for pediatric patients.

RECENT FINDINGS

This review outlines clinical indications for transfusion of fresh frozen plasma, cryoprecipitate, platelets, and fibrinogen concentrate in pediatrics. Recent studies of non-red blood cell transfusions in critical, but stable situations are highlighted. Recommendations to guide transfusion of the 'yellow' blood products in operative and non-operative settings are summarized. Special attention is drawn to guidelines in massive hemorrhage and trauma situations.

SUMMARY

Evidence-based guidelines and expert consensus recommendations exist to guide the transfusion of pediatric non-red blood products and should be followed when transfusing the 'yellow' blood components. As high-quality studies in neonates, infants and children are limited, future research should broaden our knowledge in this direction with the goal to use restrictive strategies to improve patient outcomes.

Platelet transfusion thresholds in neonatal medicine

Thrombocytopenia is common in preterm neonates. Thresholds for prophylactic platelet transfusion vary widely due to lack of evidence. The results of the PlaNet-2/MATISSE Study identified harm in the form of mortality and major bleed in babies prophylactically transfused below a platelet count of 50 × 10⁹/L compared to 25 × 10⁹/L. Neonatal platelet transfusions are administered at volumes based on historical practice which greatly exceed those routinely used in adults. Rate of transfusion is also based around practice in trauma and does not take into account the physiology of the preterm infant. There are multiple ways in which platelets may be mediating harm and this review discusses these potential mechanisms including immunological, inflammatory and blood group incompatibility. Much of the difficulty in assessing harm relates to problems in classification of transfusion-associated adverse events in babies. Thrombocytopenia and timing, efficacy and adverse effects of platelet transfusion are poorly understood. Further research is essential.

Transfusion Management in Pediatric Oncology Patients

Pediatric oncology patients will likely require numerous transfusions of blood products, including red blood cell, platelet, and plasma transfusions, during the course of their treatment. Although strong evidence-based guidelines for these products in this patient population do not exist, given the morbidities associated with the receipt of blood products, practitioners should attempt to use restrictive transfusion strategies.