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Berenger JB, Saillard C, Sannini A, Servan L, Gonzalez F, Faucher M, de Guibert JM, Hospital MA, Bisbal M, Chow-Chine L, Mokart D. Prophylactic versus restrictive platelet transfusion strategy in patients with haematological malignancies in the ICU setting, a propensity-score analysis. J Crit Care 2024; 83:154817. [PMID: 38805833 DOI: 10.1016/j.jcrc.2024.154817] [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: 02/14/2024] [Revised: 04/20/2024] [Accepted: 04/25/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE Prophylactic platelet transfusions (PT) aim to reduce bleeding. We assessed whether restrictive PT compared to prophylactic strategy could apply in ICU. MATERIAL AND METHODS We conducted a retrospective monocentric study including patients >18 yo with haematological malignancy admitted to the ICU with thrombocytopenia <20 G/L between 2018 and 2021. Patients were classified in 2 groups according transfusion strategy applied during the first 3 days: prophylactic or restrictive transfusion. RESULTS 180 patients were included, 87 and 93 in the restrictive and prophylactic groups respectively. After propensity-score analysis, 2 groups of 54 matched patients were analyzed. Restrictive strategy led to a significant reduction in PT with incidence rate for 100-ICU-patients-days of 34.9 and 49.9, incidence rate ratio = 0.699 [0.5-0.9], p = 0.006, representing a 31% decrease. Decreased PT persisted until day 28 with platelet concentrates transfusions-free days at day 28 of 21 [13-25] and 16.5 [10.2-21] in the 2 groups (p = 0.04). Restrictive strategy did not result in higher grade ≥ 2 bleeding. Transfusion efficiency was low with similar number of days with platelet <10 or < 20 G/L regardless of strategy. Platelet transfusion strategy was not associated with 28-day mortality. Platelet nadir <5G/L was associated with day-28 mortality with HR = 1.882 [1.011-3.055], p = 0.046. CONCLUSION A restrictive PT strategy appears feasible in the ICU.
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Affiliation(s)
- Jean-Baptiste Berenger
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Colombe Saillard
- Haematology Department, Institut Paoli Calmettes, Marseille, France
| | - Antoine Sannini
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Luca Servan
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Frederic Gonzalez
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Marion Faucher
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Jean-Manuel de Guibert
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | | | - Magali Bisbal
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Laurent Chow-Chine
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Djamel Mokart
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France.
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Zanetto A, Campello E, Senzolo M, Simioni P. The evolving knowledge on primary hemostasis in patients with cirrhosis: A comprehensive review. Hepatology 2024; 79:460-481. [PMID: 36825598 DOI: 10.1097/hep.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/13/2023] [Indexed: 02/25/2023]
Abstract
Patients with cirrhosis develop complex alterations in primary hemostasis that include both hypocoagulable and hypercoagulable features. This includes thrombocytopenia, multiple alterations of platelet function, and increased plasma levels of von Willebrand factor. Contrary to the historical view that platelet dysfunction in cirrhosis might be responsible for an increased bleeding tendency, the current theory posits a rebalanced hemostasis in patients with cirrhosis. Severe thrombocytopenia is not indicative of the bleeding risk in patients undergoing invasive procedures and does not dictate per se the need for pre-procedural prophylaxis. A more comprehensive and individualized risk assessment should combine hemostatic impairment, the severity of decompensation and systemic inflammation, and the presence of additional factors that may impair platelet function, such as acute kidney injury and bacterial infections. Although there are multiple, complex alterations of platelet function in cirrhosis, their net effect is not yet fully understood. More investigations evaluating the association between alterations of platelet function and bleeding/thrombosis may improve risk stratification in patients with decompensated cirrhosis. Besides hemostasis, the assessment of von Willebrand factor Ag and ADP-induced, whole-blood platelet aggregation normalized by platelet count (VITRO score and PLT ratio) are promising biomarkers to predict the risk of hepatic decompensation and survival in both compensated and decompensated patients. Further investigations into the in vivo interplay between platelets, circulating blood elements, and endothelial cells may help advance our understanding of cirrhotic coagulopathy. Here, we review the complex changes in platelets and primary hemostasis in cirrhosis and their potential clinical implications.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale-Università Padova, Padova, Italy
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Elena Campello
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale-Università Padova, Padova, Italy
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Paolo Simioni
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
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3
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Lv W, Jiang X, Zhang Y. The role of platelets in the blood-brain barrier during brain pathology. Front Cell Neurosci 2024; 17:1298314. [PMID: 38259501 PMCID: PMC10800710 DOI: 10.3389/fncel.2023.1298314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024] Open
Abstract
Platelets play critical roles in maintaining hemostasis. The blood brain barrier (BBB), a significant physical and metabolic barrier, helps maintain physiological stability by limiting transportations between the blood and neural tissues. When the brain undergoes inflammation, tumor, trauma, or bleeding, the platelet responses to help with maintaining BBB homeostasis. In the traditional point of view, activated platelets aggregate to form thrombi which cover the gaps of the blood vessels to protect BBB. However, increasing evidences indicate that platelets may harm BBB by enhancing vascular permeability. Hereby, we reviewed recently published articles with a special focus on the platelet-mediated damage of BBB. Factors released by platelets can induce BBB permeability, which involve platelet-activating factors (PAF), P-selectin, ADP, platelet-derived growth factors (PDGF) superfamily proteins, especially PDGF-AA and PDGF-CC, etc. Platelets can also secrete Amyloid-β (Aβ), which triggers neuroinflammation and downregulates the expression of tight junction molecules such as claudin-5 to damage BBB. Additionally, platelets can form aggregates with neutrophils to release reactive oxygen species (ROS), which can destroy the DNA, proteins, and lipids of endothelial cells (ECs). Moreover, platelets participate in neuroinflammation to affect BBB. Conversely, some of the platelet released factors such as PDGF-BB, protects BBB. In summary, platelets play dual roles in BBB integrity and the related mechanisms are reviewed.
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Affiliation(s)
| | - Xiaofan Jiang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yanyu Zhang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
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4
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Evans HG, Murphy MF, Foy R, Dhiman P, Green L, Kotze A, von Neree L, Palmer AJ, Robinson SE, Shah A, Tomini F, Trompeter S, Warnakulasuriya S, Wong WK, Stanworth SJ. Harnessing the potential of data-driven strategies to optimise transfusion practice. Br J Haematol 2024; 204:74-85. [PMID: 37964471 DOI: 10.1111/bjh.19158] [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: 08/05/2023] [Revised: 09/24/2023] [Accepted: 10/03/2023] [Indexed: 11/16/2023]
Abstract
No one doubts the significant variation in the practice of transfusion medicine. Common examples are the variability in transfusion thresholds and the use of tranexamic acid for surgery with likely high blood loss despite evidence-based standards. There is a long history of applying different strategies to address this variation, including education, clinical guidelines, audit and feedback, but the effectiveness and cost-effectiveness of these initiatives remains unclear. Advances in computerised decision support systems and the application of novel electronic capabilities offer alternative approaches to improving transfusion practice. In England, the National Institute for Health and Care Research funded a Blood and Transplant Research Unit (BTRU) programme focussing on 'A data-enabled programme of research to improve transfusion practices'. The overarching aim of the BTRU is to accelerate the development of data-driven methods to optimise the use of blood and transfusion alternatives, and to integrate them within routine practice to improve patient outcomes. One particular area of focus is implementation science to address variation in practice.
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Affiliation(s)
- H G Evans
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - M F Murphy
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | - R Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - P Dhiman
- Centre for Statistics in Medicine, Botnar Research Centre, Oxford, UK
| | - L Green
- Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
- NHS Blood and Transplant, London, UK
| | - A Kotze
- Leeds Teaching Hospitals, Leeds, UK
| | - L von Neree
- University College London Hospitals NHS Foundation Trust, London, UK
| | - A J Palmer
- Nuffield Orthopaedic Centre, Oxford University NHS Foundation Trust, Oxford, UK
| | - S E Robinson
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - F Tomini
- Queen Mary University of London, London, UK
| | - S Trompeter
- University College London Hospitals NHS Foundation Trust, London, UK
- University College London, London, UK
| | - S Warnakulasuriya
- University College London Hospitals NHS Foundation Trust, London, UK
- University College London, London, UK
| | - W K Wong
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S J Stanworth
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
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5
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Lim HJ, Jang H, Lee N, Jeong E, Park Y, Jo Y, Kim J, Lee YE, Choi HJ, Kee SJ, Shin JH, Shin MG. Prediction of Mid-term Platelet Transfusion in Stable Trauma Patients Using Rotational Thromboelastometry. Ann Lab Med 2024; 44:74-81. [PMID: 37665288 PMCID: PMC10485857 DOI: 10.3343/alm.2024.44.1.74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/05/2023] [Accepted: 08/04/2023] [Indexed: 09/05/2023] Open
Abstract
Background Rotational thromboelastometry (ROTEM; TEM International GmbH, Munich, Germany) is a global coagulation test that guides evidence-based platelet transfusion in trauma patients. We evaluated ROTEM parameters for predicting mid-term (five days) platelet transfusion in trauma patients. Methods Maximum clot firmness and clot amplitudes after 5, 10, and 15 mins (A5, A10, and A15, respectively) of fibrin-specific ROTEM (FIBTEM) and extrinsically activated ROTEM (EXTEM) were retrospectively collected from 82 hospitalized, stable, non-bleeding trauma patients after successful initial resuscitation. Platelet-specific ROTEM (PLTEM) was calculated by subtracting FIBTEM from EXTEM. Platelet transfusions were reviewed for five days after ROTEM. Results The areas under the curve for FIBTEM, EXTEM, and PLTEM predicting platelet concentrate transfusion of >12 U at mid-term were 0.915-0.923, 0.878-0.896, and 0.551-0.735, respectively. FIBTEM and EXTEM parameters were comparable to those of fibrinogen, fibrin/fibrinogen degradation products, D-dimer, and antithrombin III. Strong correlations (r>0.7) were noted between platelet count and EXTEM (A5, A10, and A15) or PLTEM (A5), platelet function (per platelet count) and EXTEM (A10 and A15), and fibrinogen levels and all FIBTEM parameters. Conclusions FIBTEM and EXTEM can reliably predict mid-term platelet transfusion in trauma patients. FIBTEM, EXTEM, and PLTEM parameters correlate with conventional coagulation tests (platelets and fibrinogen).
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Affiliation(s)
- Ha Jin Lim
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Hyunseok Jang
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Naa Lee
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Euisung Jeong
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Yunchul Park
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Younggoun Jo
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Jungchul Kim
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Young Eun Lee
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Hyun-Jung Choi
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Seung-Jung Kee
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Jong Hee Shin
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Myung Geun Shin
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, Korea
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6
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Maier CL, Stanworth SJ, Sola-Visner M, Kor D, Mast AE, Fasano R, Josephson CD, Triulzi DJ, Nellis ME. Prophylactic Platelet Transfusion: Is There Evidence of Benefit, Harm, or No Effect? Transfus Med Rev 2023; 37:150751. [PMID: 37599188 DOI: 10.1016/j.tmrv.2023.150751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 08/22/2023]
Abstract
The optimal use of prophylactic platelet transfusion remains uncertain in a number of clinical scenarios. Platelet count thresholds have been established in patients with hematologic malignancies, yet thresholds backed by scientific data are limited or do not exist for many patient populations. Clinical scenarios involving transfusion thresholds for thrombocytopenic patients with critical illness, need for surgery or invasive procedures, or those involving specials populations like children and neonates, lack clear evidence for discerning favorable outcomes without undue risk related to platelet transfusion. In addition, while prophylactic platelet transfusions are administered with the goal of enhancing hemostasis, increasing evidence supports critical nonhemostatic roles for platelets related to innate and adaptive immunity, inflammation, and angiogenesis, which may impact patient responses and outcomes. Here we review several recent studies conducted in adult or pediatric patients that highlight the limitations in our current understanding of prophylactic platelet transfusion. Together, these studies underscore the need for additional research, especially in the form of robust randomized clinical trials and integrating additional parameters beyond the platelet count. Future research at the basic, translational, and clinical levels will best define the optimal role for prophylactic transfusion across the lifespan and its broader impact on health and disease.
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Affiliation(s)
- Cheryl L Maier
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Simon J Stanworth
- NHSBT; Oxford University Hospitals NHS Foundation Trust; Radcliffe Department of Medicine, University of Oxford; Oxford, United Kingdom
| | | | - Daryl Kor
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Allan E Mast
- Department of Cell Biology, Neurobiology and Anatomy, Versiti Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ross Fasano
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Cassandra D Josephson
- Department of Oncology, Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Darrell J Triulzi
- Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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7
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Stanworth SJ, Shah A, Doidge J, Watkinson P. The ongoing dilemma of prophylactic platelet transfusions pre-procedure and the development of evidence-based recommendations. Transfus Med 2023; 33:428-430. [PMID: 37712550 DOI: 10.1111/tme.12994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/18/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Simon J Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Akshay Shah
- Intensive Care National Audit and Research Centre, and London School of Hygiene & Tropical Medicine, London, UK
| | - James Doidge
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Peter Watkinson
- Intensive Care National Audit and Research Centre, and London School of Hygiene & Tropical Medicine, London, UK
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8
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Hendrickson JE, Ortel TL. Introduction to a How I Treat series on consultative hematology for inpatients. Blood 2023; 142:751-752. [PMID: 37167420 DOI: 10.1182/blood.2023019877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 05/13/2023] Open
Abstract
Associate Editors Hendrickson and Ortel edited a How I Treat series on inpatient consultative hematology. In this timely series of articles, the authors present an approach to bleeding, thrombosis, anemia, and quantitative neutrophil abnormalities.
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Bargehr C, Knöfler R, Streif W. Treatment of Inherited Platelet Disorders: Current Status and Future Options. Hamostaseologie 2023; 43:261-270. [PMID: 37611608 DOI: 10.1055/a-2080-6602] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
Inherited platelet disorders (IPDs) comprise a heterogeneous group of entities that manifest with variable bleeding tendencies. For successful treatment, the underlying platelet disorder, bleeding severity and location, age, and sex must be considered in the broader clinical context. Previous information from the AWMF S2K guideline #086-004 (www.awmf.org) is evaluated for validity and supplemented by information of new available and future treatment options and clinical scenarios that need specific measures. Special attention is given to the treatment of menorrhagia and risk management during pregnancy in women with IPDs. Established treatment options of IPDs include local hemostatic treatment, tranexamic acid, desmopressin, platelet concentrates, and recombinant activated factor VII. Hematopoietic stem cell therapy is a curative approach for selected patients. We also provide an outlook on promising new therapies. These include autologous hematopoietic stem cell gene therapy, artificial platelets and nanoparticles, and various other procoagulant treatments that are currently tested in clinical trials in the context of hemophilia.
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Affiliation(s)
- Caroline Bargehr
- Department of Paediatrics 1, Medical University of Innsbruck, Innsbruck, Austria
| | - Ralf Knöfler
- Department of Paediatric Haemostaseology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Werner Streif
- Department of Paediatrics 1, Medical University of Innsbruck, Innsbruck, Austria
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Goubran H, Ragab G, Seghatchian J, Burnouf T. Blood transfusion in autoimmune rheumatic diseases. Transfus Apher Sci 2022; 61:103596. [DOI: 10.1016/j.transci.2022.103596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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11
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Crowe EP, Tobian AAR. Component modifications and acute transfusion reactions: Important then, more to learn now. Transfusion 2022; 62:2172-2183. [PMID: 36151944 DOI: 10.1111/trf.17130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/14/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Elizabeth P Crowe
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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