Red blood cell transfusion in myelodysplastic syndromes: A systematic review

Immunophenotyping myelodysplastic neoplasms: the role of flow cytometry in the molecular classification era

The unique heterogenous landscape of myelodysplastic syndromes/neoplasms (MDS) has resulted in continuous redefinition of disease sub-entities, in view of the novel translational research data that have clarified several areas of the pathogenesis and the progression of the disease. The new international classifications (WHO 2022, ICC 2022) have incorporated genomic data defining phenotypical alterations, that guide clinical management of specific patient subgroups. On the other hand, for over a decade, multiparameter flow cytometry (MFC) has proven its value as a complementary diagnostic tool for these diseases and although it has never been established as a mandatory test for the baseline evaluation of MDS patients in international guidelines, it is almost universally adopted in everyday clinical practice for the assessment of suspected cytopenias through simplified scoring systems or elaborate analytical strategies for the detection of immunophenotypical dysplastic features in every hematopoietic cell lineage in the bone marrow (BM). In this review, we explore the clinically meaningful interplay of MFC data and genetic profiles of MDS patients, to reveal the currently existing and the potential future role of each methodology for routine clinical practice, and the benefit of the patients. We reviewed the existing knowledge and recent advances in the field and discuss how an integrated approach could lead to patient re-stratification and guide personalized management.

Ferric Carboxymaltose and Erythropoiesis-Stimulating Agent Treatment Reduces the Rate of Blood Transfusion in Refractory Anemia

Background: Erythropoiesis-stimulating agents (ESAs) are used to treat refractory anemia (RA). Guidelines suggest iron supplementation for unresponsive patients, regardless of iron deficiency. The primary aim of this study was to evaluate the effect of iron supplementation with ferric carboxymaltose (FCM) on the reduction of red blood cell transfusion (RBCT) rate in transfusion-dependent RA patients. Methods: This was a prospective quasi-randomized study, wherein patients were randomly assigned into three groups: (A) ESAs alone, (B) ferric gluconate (FG) and ESAs, and (C) FCM and ESAs. Hemoglobin and ferritin levels, as well as the number of RBCTs at 4 and 28 weeks were compared. Economic evaluation was also performed. Results: A total of 113 RA patients were enrolled. In total, 43 were treated with intravenous FG and ESAs, 38 with FCM and ESAs, and 32 with ESAs alone. At both follow-ups, erythropoietic response was increased in those receiving iron as compared with those with ESAs alone (p = 0.001), regardless of the type of iron. At one month, ferritin levels were higher in the FCM and ESA groups (p = 0.001). RBCTs were lower in both iron groups. The less costly treatment strategy was FCM, followed by FG, and lastly ESAs. Conclusions: Addition of iron to ESAs in RA reduced RBCT requirement and improved hemoglobin values.

Exploring the rationale for red cell transfusion in myelodysplastic syndrome patients: emerging data and future insights

INTRODUCTION

Anemia is often present in mostly elderly patients with myelodysplastic syndromes (MDS), and is associated with a poorer outcome. Although Red blood cell (RBC) transfusions are the most immediate treatment, waiting for the response to disease-specific therapy, or in case of non-response, the choice of the optimal transfusion regimen is still controversial.

AREAS COVERED

The main objectives of RBC transfusion are the control of anemia-related symptoms and complications and the improvement of functional status and of health-related quality of life (HRQoL). However, RBC transfusions are associated with several negative clinical consequences, mainly adverse transfusion reactions and iron overload, which can be counteracted by iron chelation therapy. Recent few pilot prospective trials have shown a benefit, in terms of HRQoL, of more liberal transfusion regimens, with higher haemoglobin (Hb) targets, compared to conventional restrictive regimens, but these results need confirmation by larger studies.

EXPERT OPINION

: A patient-oriented RBC transfusion therapy in MDS patients must take into account several laboratory (Hb), clinical (age, comorbidities), psychological, family and social factors, and evaluation of HRQoL should become a fundamental parameter in assessing the clinical benefit of therapy. Many questions remain to be clarified, including why some patients report little benefit from transfusions.