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Clerici B, Masood S, Nazy I, Tang N, Cranstone M, Liu Y, Hadzi-Tosev M, Nixon J, St John M, Shirinzadeh M, Jamula E, Kelton JG, Arnold DM. Bleeding self-assessments by patients with immune thrombocytopenia (ITP): An agreement study. Am J Hematol 2024; 99:1184-1186. [PMID: 38534202 DOI: 10.1002/ajh.27298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 03/28/2024]
Abstract
We designed anagreement study to compare the results of bleeding assessments done in tandem by ITP patients and trained research staff. We used a modified version of the ITP Bleeding Scale, which captured the patients' worst bleeding event at any of nine anatomical sites since the time of the last assessment. Interrater agreement was determined using the 2-way kappa for the assessment of severe vs. non-severe bleeds. We analyzed 108 consecutive patients with ITP from the McMaster ITP Registry who had duplicate bleeding assessments. Two-way agreement was excellent for gynecological (k = 0.86, 95% CI 0.71-1.02), gastrointestinal (k = 1), genitourinary (k = 1), pulmonary (k = 1) and intracranial (k = 1) bleeds; good for skin (k = 0.68, 95% CI, 0.54-0.82), oral (k = 0.76, 95% CI, 0.53-0.98) and ocular (k = 0.66, 95% CI, 0.04-1-28) bleeds; and moderate for epistaxis (k = 0.58, 95% CI, 0.21-0.95). Bleeding self-assessments by ITP patients were similar to trained research staff, but disagreements in severity grades were more frequent with skin bleeds, oral bleeds and epistaxis. Bleeding self-assessments could simplify bleeding assessments in clinical trials.
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Affiliation(s)
- Bianca Clerici
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Sahrish Masood
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ishac Nazy
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ngan Tang
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Madison Cranstone
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Yang Liu
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Milena Hadzi-Tosev
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Joanne Nixon
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Melanie St John
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Maryam Shirinzadeh
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Erin Jamula
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John G Kelton
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Michael G. DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Adelborg K, Veres K, Horváth-Puhó E, Clouser M, Saad H, Sørensen HT. Risk and adverse clinical outcomes of thrombocytopenia among patients with solid tumors-a Danish population-based cohort study. Br J Cancer 2024; 130:1485-1492. [PMID: 38448749 PMCID: PMC11058247 DOI: 10.1038/s41416-024-02630-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Knowledge about thrombocytopenia among patients with solid tumors is scarce. We examined the risk of thrombocytopenia among patients with solid tumors and its association with adverse outcomes. METHODS Using Danish health registries, we identified all patients with incident solid tumors from 2015-2018 (n = 52,380) and a platelet count measurement within 2 weeks prior to or on their cancer diagnosis date. The risk of thrombocytopenia was categorized as grades 0 (any platelet count × 109/L): <150; 1: <100; 2: <75; 3: <50; 4: <25, and 5: <10. To study the outcomes, each patient with thrombocytopenia was matched with up to five cancer patients without thrombocytopenia by age, sex, cancer type, and stage. Cox regression was used to compute hazard ratios (HRs) of bleeding, transfusion, or death, adjusting for confounding factors. RESULTS The 1-year risk of thrombocytopenia was 23%, increasing to 30% at 4 years. This risk was higher in patients receiving chemotherapy (43% at 1 year and 49% at 4 years). Overall, patients with thrombocytopenia had higher 30-days rates of bleeding (HR = 1.72 [95% confidence interval, CI: 1.41-2.11]). Thrombocytopenia was also associated with an increased rate of transfusion, and death, but some of the risk estimates were imprecise. CONCLUSIONS The risk of thrombocytopenia was substantial among patients with solid tumors and associated with adverse outcomes.
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Affiliation(s)
- Kasper Adelborg
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Katalin Veres
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Erzsébet Horváth-Puhó
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.
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Zhang JC, Ni LH, Tu Y, Hu HX. Related donor platelet transfusion improves platelet transfusion refractoriness in hematological patients. Front Med (Lausanne) 2023; 10:983644. [PMID: 36936203 PMCID: PMC10014593 DOI: 10.3389/fmed.2023.983644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 01/13/2023] [Indexed: 03/05/2023] Open
Abstract
Objective Transfusion of HLA-matched platelets can reduce the effect of alloimmune responses on platelet transfusion efficacy; however, finding HLA-matched platelets in the population is nearly impossible. Almost all HLA-matched platelets from related are half-matched, but the hemostatic efficacy of related donor platelets is unclear. Our goal was to compare the hemostatic effect of related donated platelets and unrelated donors platelets. Methods In this retrospective cohort study, we included acute leukemia and myelodysplastic syndrome patients with thrombocytopenia after chemotherapy. These patients were all transfused with platelets. This study excluded patients younger than 16 years and older than 65 years, or patients with abnormal coagulation parameters during platelet transfusion. We compared the hemostatic effect of related donated platelets and unrelated donors platelet. The primary outcome was transfusion efficacy after platelet transfusion, and the number of platelet counts and corrected count increments at 24 h after platelet transfusion. Result We analyzed 31 patients who received platelet transfusions from related donors (Treatment group) and 35 patients who received platelet transfusions from unrelated donors (Comparator group). Except for the relatively small proportion of patients with myelodysplastic syndrome in the treatment group, baseline clinical and laboratory characteristics were similar between the two groups. Hemostasis and prevention of bleeding in the treatment group showed significant superiority; the number of platelets increased 24 h after platelet transfusion in the treatment group was significantly higher than that in the comparator group. After 24 h, the corrected count increments treatment group was also higher than the comparator group; in the treatment group, the transfusion effect was better when the three sites of HLA-A, B, and C were identical, and the different blood types of platelet donors and recipients did not affect the transfusion effect. Conclusion Related donated platelets have better hemostasis and prevention effects, and no increase in adverse blood transfusion reactions. It may be a better transfusion strategy for platelet refractoriness patients in emergency situations.
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Quehenberger P, Löffler MW, Wiegele M, Schaden E, Lacom C, Tolios A, Eichelberger B. Assay validity of point-of-care platelet function tests in thrombocytopenic blood samples. Biochem Med (Zagreb) 2022; 32:020713. [PMID: 35799989 PMCID: PMC9195599 DOI: 10.11613/bm.2022.020713] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 04/29/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction Point-of-care (POC) platelet function tests are faster and easier to perform than in-depth assessment by flow cytometry. At low platelet counts, however, POC tests are prone to assess platelet function incorrectly. Lower limits of platelet count required to obtain valid test results were defined and a testing method to facilitate comparability between different tests was established. Materials and methods We assessed platelet function in whole blood samples of healthy volunteers at decreasing platelet counts (> 100, 80-100, 50-80, 30-50 and < 30 x109/L) using two POC tests: impedance aggregometry and in-vitro bleeding time. Flow cytometry served as the gold standard. The number of platelets needed to reach 50% of the maximum function (ED50) and the lower reference limit (EDref) were calculated to define limits of test validity. Results The minimal platelet count required for reliable test results was 100 x109/L for impedance aggregometry and in-vitro bleeding time but only 30 x109/L for flow cytometry. Comparison of ED50 and EDref showed significantly lower values for flow cytometry than either POC test (P value < 0.05) but no difference between POC tests nor between the used platelet agonists within a test method. Conclusion Calculating the ED50 and EDref provides an effective way to compare values from different platelet function assays. Flow cytometry enables correct platelet function testing as long as platelet count is > 30 x109/L whereas impedance aggregometry and in-vitro bleeding time are inconsistent unless platelet count is > 100 x109/L.
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Affiliation(s)
- Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus W. Löffler
- Department of Immunology, Interfaculty Institute for Cell Biology, University of Tübingen, Tübingen, Germany
| | - Marion Wiegele
- Department of Anaesthesia, Critical Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Eva Schaden
- Department of Anaesthesia, Critical Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Conrad Lacom
- Department of Anaesthesia, Critical Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Alexander Tolios
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Beate Eichelberger
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
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5
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Tullemans BME, Brouns SLN, Swieringa F, Sabrkhany S, van den Berkmortel FWPJ, Peters NAJB, de Bruijn P, Koolen SLW, Heemskerk JWM, Aarts MJB, Kuijpers MJE. Quantitative and qualitative changes in platelet traits of sunitinib-treated patients with renal cell carcinoma in relation to circulating sunitinib levels: a proof-of-concept study. BMC Cancer 2022; 22:653. [PMID: 35698081 PMCID: PMC9195440 DOI: 10.1186/s12885-022-09676-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 05/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Tyrosine kinase inhibitors (TKIs), such as sunitinib, are used for cancer treatment, but may also affect platelet count and function with possible hemostatic consequences. Here, we investigated whether patient treatment with the TKI sunitinib affected quantitative and qualitative platelet traits as a function of the sunitinib level and the occurrence of bleeding. Methods Blood was collected from 20 metastatic renal cell carcinoma (mRCC) patients before treatment, and at 2 weeks, 4 weeks and 3 months after sunitinib administration. We measured blood cell counts, platelet aggregation, and concentrations of sunitinib as well as its N-desethyl metabolite in plasma, serum and isolated platelets. Progression of disease (PD) and bleeding were monitored after 3 months. Results In sunitinib-treated mRCC patients, concentrations of (N-desethyl-)sunitinib in plasma and serum were highly correlated. In the patients’ platelets the active metabolite levels were relatively increased as compared to sunitinib. On average, a sustained reduction in platelet count was observed on-treatment, which was significantly related to the inhibitor levels in plasma/serum. Principal component and correlational analysis showed that the (N-desethyl-)sunitinib levels in plasma/serum were linked to a reduction in both platelet count and collagen-induced platelet aggregation. The reduced aggregation associated in part with reported bleeding, but did not correlate to PD. Conclusion The sunitinib-induced reduction in quantitative and qualitative platelet traits may reflect the effective sunitinib levels in the patient. These novel results may serve as a proof-of-principle for other TKI-related drugs, where both platelet count and functions are affected, which could be used for therapeutic drug monitoring. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09676-0.
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Affiliation(s)
- Bibian M E Tullemans
- Cardiovascular Research Institute Maastricht, Department of Biochemistry, Maastricht University, Maastricht, The Netherlands
| | - Sanne L N Brouns
- Cardiovascular Research Institute Maastricht, Department of Biochemistry, Maastricht University, Maastricht, The Netherlands
| | - Frauke Swieringa
- Cardiovascular Research Institute Maastricht, Department of Biochemistry, Maastricht University, Maastricht, The Netherlands.,Synapse Research Institute, Maastricht, The Netherlands
| | - Siamack Sabrkhany
- Cardiovascular Research Institute Maastricht, Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | | | | | - Peter de Bruijn
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Centre, Rotterdam, The Netherlands.,Department of Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Johan W M Heemskerk
- Cardiovascular Research Institute Maastricht, Department of Biochemistry, Maastricht University, Maastricht, The Netherlands.,Synapse Research Institute, Maastricht, The Netherlands
| | - Maureen J B Aarts
- Department of Medical Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marijke J E Kuijpers
- Cardiovascular Research Institute Maastricht, Department of Biochemistry, Maastricht University, Maastricht, The Netherlands. .,Thrombosis Expertise Centre, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.
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An epitope-based approach of HLA-matched platelets for transfusion: a noninferiority crossover randomized trial. Blood 2021; 137:310-322. [PMID: 33475737 DOI: 10.1182/blood.2020007199] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/21/2020] [Indexed: 11/20/2022] Open
Abstract
Platelet transfusion refractoriness results in adverse outcomes and increased health care costs. Managing refractoriness resulting from HLA alloimmunization necessitates the use of HLA antigen-matched platelets but requires a large platelet donor pool and does not guarantee full matching. We report the first randomized, double-blind, noninferiority, crossover trial comparing HLA epitope-matched (HEM) platelets with HLA standard antigen-matched (HSM) platelet transfusions. Alloimmunized, platelet-refractory, thrombocytopenic patients with aplastic anemia, myelodysplastic syndrome, or acute myeloid leukemia were eligible. HEM platelets were selected using HLAMatchMaker epitope (specifically eplet) matching. Patients received up to 8 prophylactic HEM and HSM transfusions provided in random order. The primary outcome was 1-hour posttransfusion platelet count increment (PCI). Forty-nine patients were randomized at 14 UK hospitals. For intention to treat, numbers of evaluable transfusions were 107 and 112 for HEM and HSM methods, respectively. Unadjusted mean PCIs for HEM and HSM methods were 23.9 (standard deviation [SD], 15) and 23.5 (SD, 14.1), respectively (adjusted mean difference, -0.1; 95% confidence interval [CI], -2.9 to 2.8). Because the lower limit of the 95% CI was not greater than the predefined noninferiority limit, the HEM approach was declared noninferior to the HSM approach. There were no differences in secondary outcomes of platelet counts, transfusion requirements, and bleeding events. Adequate 1-hour PCI was more frequently observed, with a mean number of 3.2 epitope mismatches, compared with 5.5 epitope mismatches for inadequate 1-hour increments. For every additional epitope mismatch, the likelihood of an adequate PCI decreased by 15%. Epitope-matched platelets should be considered to support HLA alloimmunized patients. This trial was registered at www.isrctn.com as #ISRCTN23996532.
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7
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The effect of variation in donor platelet function on transfusion outcome: a semirandomized controlled trial. Blood 2017; 130:214-220. [PMID: 28487294 DOI: 10.1182/blood-2017-01-759258] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/22/2017] [Indexed: 11/20/2022] Open
Abstract
The effect of variation in platelet function in platelet donors on patient outcome following platelet transfusion is unknown. This trial assessed the hypothesis that platelets collected from donors with highly responsive platelets to agonists in vitro assessed by flow cytometry (high-responder donors) are cleared more quickly from the circulation than those from low-responder donors, resulting in lower platelet count increments following transfusion. This parallel group, semirandomized double-blinded trial was conducted in a single center in the United Kingdom. Eligible patients were those 16 or older with thrombocytopenia secondary to bone marrow failure, requiring prophylactic platelet transfusion. Patients were randomly assigned to receive a platelet donation from a high- or low-responder donor when both were available, or when only 1 type of platelet was available, patients received that. Participants, investigators, and those assessing outcomes were masked to group assignment. The primary end point was the platelet count increment 10 to 90 minutes following transfusion. Analysis was by intention to treat. Fifty-one patients were assigned to receive platelets from low-responder donors, and 49 from high-responder donors (47 of which were randomized and 53 nonrandomized). There was no significant difference in platelet count increment 10 to 90 minutes following transfusion in patients receiving platelets from high-responder (mean, 21.0 × 109/L; 95% confidence interval [CI], 4.9-37.2) or low-responder (mean, 23.3 × 109/L; 95% CI, 7.8-38.9) donors (mean difference, 2.3; 95% CI, -1.1 to 5.7; P = .18). These results support the current policy of not selecting platelet donors on the basis of platelet function for prophylactic platelet transfusion.
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Vinholt PJ, Alnor A, Nybo M, Hvas AM. Prediction of bleeding and prophylactic platelet transfusions in cancer patients with thrombocytopenia. Platelets 2016; 27:547-54. [DOI: 10.3109/09537104.2015.1131814] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Pernille J. Vinholt
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense C, Denmark
| | - Anne Alnor
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense C, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense C, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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Abstract
To better understand the clinical features, therapy, and clinical outcome of Chinese patients with immune thrombocytopenia (ITP) who suffered severe hemorrhage, we retrospectively analyzed 663 children with ITP diagnosed in our hospital during the last 10 years. Of the total 663 patients enrolled in our study, 520 were eligible for bleeding severity assessment, of which 20 children (3.8%) had severe bleeding, including intracranial hemorrhage (ICH) (n = 9), gastrointestinal hemorrhage (n = 6), massive epistaxis (n = 3), urinary tract hemorrhage (n = 1), and pulmonary hemorrhage (n = 1). The age at diagnosis of severe hemorrhage ranged from 47 days to 14 years. Thirteen patients were newly diagnosed with ITP, 3 had persistent ITP, and 4 had chronic ITP. The latency between the onset of ITP and severe bleeding ranged from 6 hours to 10 years. The median platelet count at the time of severe hemorrhage was 6.5 × 10/L (range, 0 to 32 × 10/L). Most patients with severe hemorrhage were treated with intravenous immunoglobulin (90%), corticosteroids (65%), or both (60%). Two patients (10%) died because of ICH and pulmonary hemorrhage, respectively. Four patients (20%) recovered from thrombocytopenia. Our observation showed that severe hemorrhage is rare but can occur anywhere and at any time during the course of ITP. The majority of children with ITP in China should be observed rather than treated.
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Vinholt PJ, Hvas AM, Nybo M. An overview of platelet indices and methods for evaluating platelet function in thrombocytopenic patients. Eur J Haematol 2014; 92:367-76. [PMID: 24400878 DOI: 10.1111/ejh.12262] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2013] [Indexed: 12/17/2022]
Abstract
Thrombocytopenia is associated with bleeding risk. However, in thrombocytopenic patients, platelet count does not correlate with bleeding risk and other factors are thus likely to contribute to this risk. This review presents currently available platelet-related markers available on automated haematology analysers and commonly used methods for testing platelet function. The test principles, advantages and disadvantages of each test are described. We also evaluate the current literature regarding the clinical utility of the test for prediction of bleeding in thrombocytopenia in haematological and oncological diseases. We find that several platelet-related markers are available, but information about the clinical utility in thrombocytopenia is limited. Studies support that mean platelet volume (MPV) can aid diagnosing the cause of thrombocytopenia and low MPV may be associated with bleeding in thrombocytopenia. Flow cytometry, platelet aggregometry and platelet secretion tests are used to diagnose specific platelet function defects. The flow cytometric activation marker P-selectin and surface coverage by the Cone-and-Plate[let] analyser predict bleeding in selected thrombocytopenic populations. To fully uncover the clinical utility of platelet-related tests, information about the prevalence of platelet function defects in thrombocytopenic conditions is required. Finally, knowledge of the performance in thrombocytopenic samples from patients is essential.
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Affiliation(s)
- Pernille J Vinholt
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
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Stanworth SJ, Estcourt LJ, Powter G, Kahan BC, Dyer C, Choo L, Bakrania L, Llewelyn C, Littlewood T, Soutar R, Norfolk D, Copplestone A, Smith N, Kerr P, Jones G, Raj K, Westerman DA, Szer J, Jackson N, Bardy PG, Plews D, Lyons S, Bielby L, Wood EM, Murphy MF. A no-prophylaxis platelet-transfusion strategy for hematologic cancers. N Engl J Med 2013; 368:1771-80. [PMID: 23656642 DOI: 10.1056/nejmoa1212772] [Citation(s) in RCA: 300] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The effectiveness of platelet transfusions to prevent bleeding in patients with hematologic cancers remains unclear. This trial assessed whether a policy of not giving prophylactic platelet transfusions was as effective and safe as a policy of providing prophylaxis. METHODS We conducted this randomized, open-label, noninferiority trial at 14 centers in the United Kingdom and Australia. Patients were randomly assigned to receive, or not to receive, prophylactic platelet transfusions when morning platelet counts were less than 10×10(9) per liter. Eligible patients were persons 16 years of age or older who were receiving chemotherapy or undergoing stem-cell transplantation and who had or were expected to have thrombocytopenia. The primary end point was bleeding of World Health Organization (WHO) grade 2, 3, or 4 up to 30 days after randomization. RESULTS A total of 600 patients (301 in the no-prophylaxis group and 299 in the prophylaxis group) underwent randomization between 2006 and 2011. Bleeding of WHO grade 2, 3, or 4 occurred in 151 of 300 patients (50%) in the no-prophylaxis group, as compared with 128 of 298 (43%) in the prophylaxis group (adjusted difference in proportions, 8.4 percentage points; 90% confidence interval, 1.7 to 15.2; P=0.06 for noninferiority). Patients in the no-prophylaxis group had more days with bleeding and a shorter time to the first bleeding episode than did patients in the prophylaxis group. Platelet use was markedly reduced in the no-prophylaxis group. A prespecified subgroup analysis identified similar rates of bleeding in the two study groups among patients undergoing autologous stem-cell transplantation. CONCLUSIONS The results of our study support the need for the continued use of prophylaxis with platelet transfusion and show the benefit of such prophylaxis for reducing bleeding, as compared with no prophylaxis. A significant number of patients had bleeding despite prophylaxis. (Funded by the National Health Service Blood and Transplant Research and Development Committee and the Australian Red Cross Blood Service; TOPPS Controlled-Trials.com number, ISRCTN08758735.).
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Affiliation(s)
- Simon J Stanworth
- National Health Service (NHS) Blood and Transplant, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, and Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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12
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Estcourt LJ, Heddle N, Kaufman R, McCullough J, Murphy MF, Slichter S, Wood EM, Stanworth SJ. The challenges of measuring bleeding outcomes in clinical trials of platelet transfusions. Transfusion 2013; 53:1531-43. [DOI: 10.1111/trf.12058] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 08/17/2012] [Accepted: 08/22/2012] [Indexed: 11/30/2022]
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Vamvakas EC. Meta-analysis of the studies of bleeding complications of platelets pathogen-reduced with the Intercept system. Vox Sang 2011; 102:302-16. [PMID: 21957897 DOI: 10.1111/j.1423-0410.2011.01555.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The eligibility criteria of a previously reported meta-analysis (Transfusion 2011;51:1058-1071) of randomized controlled trials (RCTs) of pathogen reduction of platelets in patients with hypoproliferative thrombocytopenia were modified to examine the impact on the findings of: (1) inclusion of a (previously excluded) RCT; (2) restriction of eligibility to RCTs of the Intercept (amotosalen-HCl/ultraviolet-A-light) system; and (3) differences in the methods used to assess bleeding complications. MATERIALS AND METHODS Five RCTs comparing the risk of all, clinically significant (grades 2 through 4) and/or severe (grades 3 and 4) bleeding complications between recipients of platelets treated with Intercept vs. standard unmanipulated platelets were included. Odds ratios (ORs) of bleeding complications of similar severity recorded during similar periods of observation were calculated across all studies and across homogeneous subsets of studies by random-effects methods. RESULTS Treatment with Intercept increased all bleeding complications when four RCTs meeting the eligibility criteria of the previous meta-analysis were integrated, but not across all the five currently available studies [summary OR=1·24; 95% confidence interval (CI), 0·79-1·93]. Clinically significant bleeding complications increased when the results of the SPRINT RCT were based on the expanded safety analysis (summary OR=1·52; 95% CI, 1·09-2·12)--but not the initial report (summary OR=1·30; 95% CI, 0·54-3·14)--of that study. CONCLUSIONS Treatment with Intercept may increase the risk of all and clinically significant (albeit not severe) bleeding complications in RCTs maintaining a platelet count of ≥10×10(9) or ≥20×10(9)/l through increased platelet transfusions.
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Affiliation(s)
- E C Vamvakas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Heddle NM, Wu C, Vassallo R, Carey P, Arnold D, Lozano M, Pavenski K, Sweeney J, Stanworth S, Liu Y, Traore A, Barty R, Tinmouth A. Adjudicating bleeding events in a platelet dose study: impact on outcome results and challenges. Transfusion 2011; 51:2304-10. [PMID: 21599672 DOI: 10.1111/j.1537-2995.2011.03181.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND In the SToP platelet dose study, the World Health Organization (WHO) bleeding grade was assigned using adjudication. This study describes the challenges associated with adjudicating bleeding events and compares the adjudicated and bedside results for bleeding grade. STUDY DESIGN AND METHODS To categorize bleeding, the following information was provided to adjudicators: daily bleeding assessments, interventions to stop or control bleeding, daily blood counts, and transfused blood components. Each daily assessment was sent to two adjudicators who independently assigned a grade and anatomic site of bleeding. Discordant cases where disagreement occurred were sent to a third adjudicator and subsequently to a fourth or fifth adjudicator in an attempt to reach agreement. Disagreement after five adjudicators was resolved by consensus. The final adjudicated grade was compared with the grade of bleeding assigned at the bedside by study personnel. RESULTS A total of 1150 case report forms were adjudicated. Disagreement on grade of bleeding was common: 31.2% after the first two adjudicators, 4.0% after the third adjudicator, 0.7% after four, and 0.05% after five. Disagreement on anatomic site was less but still occurred in 17% of cases after two adjudicators. The frequency of bleeding (≥ Grade 2) based on adjudication was higher than bedside grading (standard-dose arm, 47.5% vs. 34.4%; low-dose arm, 50.0% vs. 43.1%). CONCLUSION The frequency of WHO bleeding varies depending on the method used to assign grade. Adjudication to assign bleeding grade resulted in significant disagreement when two adjudicators were used.
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Affiliation(s)
- Nancy M Heddle
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Abstract
Although guidelines exist to deal with some aspects of platelet transfusion practice, many important clinical issues have not been addressed in large randomized controlled trials (RCTs). Slichter et al. conducted a RCT of prophylactic platelet transfusions to determine the effects of the dose of platelets on clinical signs of bleeding, the use of platelet and red cell transfusions, changes in the recipient's post-transfusion platelet count, days to next transfusion and adverse events (Effects of Prophylactic Platelet Dose on Transfusion Outcomes [PLADO] trial). The primary end point of the study (i.e., the percentage of patients in each group with at least one episode of bleeding of grade 2 or higher according to the WHO criteria) was not significantly different (71, 69 and 70% of patients in the low-, medium- and high-dose group, respectively). According to these data, one can conclude that the dose of platelets transfused has no significant effect on the incidence of bleeding in patients with hypoproliferative thrombocytopenia and platelet counts no greater than 10 × 10⁹/l.
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Affiliation(s)
- Joan Cid
- Servei d' Hemoteràpia i Hemostasia, Hospital Clínic, C/. Villarroel, 170 08036 Barcelona, Spain.
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Do all patients with hematologic malignancies and severe thrombocytopenia need prophylactic platelet transfusions? Background, rationale, and design of a clinical trial (trial of platelet prophylaxis) to assess the effectiveness of prophylactic platelet transfusions. Transfus Med Rev 2010; 24:163-71. [PMID: 20656185 DOI: 10.1016/j.tmrv.2009.11.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Although considerable advances have been made in many aspects of platelet transfusion therapy in the last 30 years, some areas continue to provoke debate, including the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding in patients with bone marrow failure. We have designed a randomized controlled trial to compare prophylactic platelet use with a threshold of a platelet count of 10 x 10(9)/L with no prophylaxis in adult thrombocytopenic patients with hematologic malignancies. The trial question is whether a no-prophylactic policy for the use of platelet transfusions in patients with hematologic malignancies is not inferior to a threshold prophylactic policy at 10 x 10(9)/L, for bleeding at World Health Organization (WHO) grade 2, 3, or 4, up to 30 days from randomization. The primary outcome measure is the proportion of patients who have a significant clinical bleed, defined as WHO grade 2 or higher up to 30 days from randomization. Subsidiary clinical outcome measures include time to first bleed and a descriptive analysis of all severe bleeds. A bleeding assessment form is completed daily for all study subjects until day 30 from randomization. Minor modifications were made to the definitions at WHO grades 1 and 2 for petechiae and duration of nose bleeds, after piloting of the bleeding assessment forms. This study has been designed as a 2-stage randomized trial with an interim analysis planned after a minimum of 100 patients had been randomized and had completed their period of observation. Patients have initially been enrolled through 3 United Kingdom hematology centers. The interim analysis has been completed, and the results have confirmed a final sample size of 600 patients. Recruitment is now being extended to other centers in United Kingdom and Australia. Local research nurses are not blinded to treatment allocation, but a number of measures to reduce risk of assessment bias include repeated education around standard operating procedures, common definitions, and duplication of assessments. The expected completion date for the 5-year study is December 2011.
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Cid J, Lozano M. Lower or higher doses for prophylactic platelet transfusions: results of a meta-analysis of randomized controlled trials. Transfusion 2007; 47:464-70. [PMID: 17319827 DOI: 10.1111/j.1537-2995.2006.01137.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are conflicting data regarding the optimal platelet (PLT) dose to transfuse prophylactically to patients with thrombocytopenia. A meta-analysis has been performed to summarize the results of different randomized controlled trials (RCTs). STUDY DESIGN AND METHODS RCTs reported through December 2005 were retrieved; five of them met the criteria for meta-analysis. Weighted mean difference (WMD) of posttransfusion PLT count increment (x10(9)/L) and transfusion interval (days) and summary odds ratio (OR) of bleeding in higher PLT dose group (HDP) versus lower PLT dose group (LDP), according to the authors, were calculated across studies. RESULTS The use of HDP was associated with an increase in the transfusion interval (WMD, 1.04 days; 95% confidence interval [CI], 0.89-1.19; p < 0.00001) when compared with the use of LDP. When the studies that guaranteed the ABO compatibility of the PLT transfusions were combined, the use of HDP was statistically associated with an increase in the posttransfusion PLT count increment when compared with the LDP group (WMD, 23.6 x 10(9)/L; 95% CI, 18.28 x 10(9) to 28.92 x 10(9)/L; p < 0.00001). When bleeding was studied, data were available in only three studies and the hypothesis of homogeneity was rejected, in 4 of 10 subgroups analyses. CONCLUSION Few RCTs have addressed the issue of PLT dose for transfusion. It is shown that the transfusion of higher doses of PLTs is statistically associated with an increase in the transfusion interval and in the posttransfusion PLT count increment. A well-designed study of enough power is essential to establish the most effective and efficient dose for prophylactic PLT transfusions.
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Affiliation(s)
- Joan Cid
- Blood and Tissue Bank, Barcelona, Spain.
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