Red Blood Cell Transfusion Strategies in Adult and Pediatric Patients with Malignancy

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Key points

  • Randomized clinical trials of red blood cell transfusion practice have provided high-quality evidence in the management of common complications of cancer.

  • The preponderance of clinical trial data supports using restrictive transfusion strategies (hemoglobin levels between 7 and 8 g/dL) in most hospitalized medical and surgical patients.

  • Additional studies are needed to understand best practice in the management of anemia in cancer patients with a focus on quality of life in addition to clinical

Goals and risks of red blood cell transfusion

The often-stated goal of RBC transfusion is to improve oxygen delivery to the tissues. However, the measurement of oxygen delivery is challenging and thresholds for transfusion are generally well above the level needed for tissue oxygenation.11 In clinical trials, the impact of RBC transfusion has been measured in relation to symptoms and clinical events. In hospitalized patients, the goal of transfusion is to maximize survival and minimize morbid events such as infection and myocardial

Risks from anemia

Symptoms and complications of anemia tend to be associated with more severe reductions in Hgb levels. According to the World Health Organization and the National Cancer Institute, normal values for Hgb are 12 to 16 g/dL in women and 14 to 18 g/dL in men, and grading of anemia is as follows: mild (grade 1), Hgb from 10 g/dL to the lower limit of normal; moderate (grade 2), Hgb 8 to 9.9 g/dL; severe (grade 3), Hgb 6.5 to 7.9 g/dL; and life threatening (grade 4), Hgb less than 6.5 g/dL.4

In

Clinical trials

There have been more than 25 clinical trials performed in adults and pediatric patients comparing liberal and restrictive RBC transfusion in greater than 12,000 patients.21, 22 These trials have been performed in many different clinical settings, including intensive care unit (ICU) patients; those undergoing cardiac, orthopedic, and other surgery; patients suffering from gastrointestinal bleeding or sepsis; and other settings. Liberal transfusion refers to RBC transfusion at higher Hgb triggers

Transfusion alternatives: erythropoiesis-stimulating agents

Recombinant human erythropoietin and other erythropoiesis-stimulating agents (ESAs) have been found to decrease the number of red blood transfusions in a variety of settings. In the US the Food and Drug Administration has approved erythropoietin for the treatment of:

  • i.

    Anemia in patients with chronic renal failure;

  • ii.

    Anemia in patients with human immunodeficiency virus infection receiving zidovudine;

  • iii.

    Highly selected cancer patients with anemia owing to myelosuppressive chemotherapy; and

  • iv.

    Patients with

Clinical guidelines

For many decades, the decision to transfuse RBCs was based on the “10/30 rule”: transfusion was used to maintain a blood Hgb level of greater than 10 g/dL and a hematocrit of greater than 30%. Since that time, a large body of clinical trial evidence has been generated, resulting in the publication of multiple society guidelines for RBC transfusion in different settings.9 Although clinical trial data focusing on patients with malignancy remains forthcoming, we emphasize available clinical trial

Future studies

Randomized, controlled clinical trials and other studies investigating optimal RBC transfusion thresholds are required to provide clinicians with evidence to guide its use in the setting of malignancy. Future studies should measure the impact of transfusion practice on several endpoints, including:

  • 1.

    Quality of life and functional status of both inpatients and outpatients;

  • 2.

    Impact on immunity and infection;

  • 3.

    Bleeding events, especially in thrombocytopenic patients;

  • 4.

    Neurocognitive development in

Summary

The preponderance of clinical trial evidence supports using a restrictive transfusion strategy (7–8 g/dL) in most medical and surgical patients. However, additional studies are needed to understand best practice in the management of acute and chronic anemia in cancer patients with a focus on quality of life in addition to clinical outcomes.

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