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Thread: Leukoreduction for the prevention of adverse reactions from allogeneic blood transfusion

  1. #1
    PharmD Year 1 TomHsiung's Avatar
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    Default Leukoreduction for the prevention of adverse reactions from allogeneic blood transfusion

    BACKGROUND:

    A blood transfusion is an acute intervention, implemented to solve life and health-threatening conditions on a short-term basis. However, blood transfusions have adverse events, some of them potentially related to immune modulation or to a direct transmission of infectious agents (e.g. cytomegalovirus). Leukoreduction is a process in which the white blood cells are intentionally reduced in packed red blood cells (PRBCs) in order to reduce the risk of adverse reactions. The potential benefits of leukoreduced PRBCs in all types of transfused patients for decreasing infectious and non-infectious complications remain unclear.

    OBJECTIVES:

    To determine the clinical effectiveness of leukoreduction of packed red blood cells for preventing adverse reactions following allogeneic blood transfusion.

    SEARCH METHODS:

    We ran the most recent search on 10th November 2015. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), MEDLINE (OvidSP), Embase(OvidSP), CINAHL Plus (EBSCO), LILACS (BIREME), and clinical trials registers. In addition, we checked the reference lists of all relevant trials and reviews identified in the literature searches.

    SELECTION CRITERIA:

    Randomised clinical trials including patients of all ages requiring PRBC allogeneic transfusion. Any study was eligible for inclusion, regardless of the length of participant follow-up or country where the study was performed. The primary outcome was transfusion-related acute lung injury (TRALI). Secondary outcomes were death from any cause, infection from any cause, non-infectious complications and any other adverse event.

    DATA COLLECTION AND ANALYSIS:

    At least two review authors independently performed study selection, 'Risk of bias' assessments and data extraction. We estimated pooled relative risk for dichotomous outcomes, and we measured statistical heterogeneity using I² statistic. The random-effects model was used to synthesise results. We conducted a trial sequential analysis to assess the risk of random errors in cumulative meta-analyses.

    MAIN RESULTS:

    Thirteen studies, most including adult patients, met the eligibility criteria. We found no clear evidence of an effect of leukoreduced PRBC versus non-leukoreduced PRBC in patients that were randomised to receive transfusion for the following outcomes: TRALI: RR 0.96, 95% CI 0.67 to 1.36, P = 0.80 from one trial reporting data on 1864 trauma patients. The accrued information of 1864 participants constituted only 28.5% of the diversity-adjusted required information size (DARIS) of 6548 participants. The quality of evidence was low. Death from any cause: RR 0.81, 95% CI 0.58 to 1.12, I² statistic = 63%, P = 0.20 from nine trials reporting data on 6485 cardiovascular surgical patients, gastro-oncology surgical patients, trauma patients and HIV infected patients. The accrued information of 6485 participants constituted only 55.3% of the DARIS of 11,735 participants. The quality of evidence was very low. Infection from any cause: RR 0.80, 95% CI 0.62 to 1.03, I² statistic = 84%, P = 0.08 from 10 trials reporting data on 6709 cardiovascular surgical patients, gastro-oncology surgical patients, trauma patients and HIV infected patients. The accrued information of 6709 participants constituted only 60.6% of the DARIS of 11,062 participants. The quality of evidence was very low.
    Adverse events: The only adverse event reported as an adverse event was fever (RR 0.81, 95% CI 0.64 to 1.02; I² statistic= 0%, P = 0.07). Fever was reported in two trials on 634 cardiovascular surgical and gastro-oncology surgical patients. The accrued information of 634 participants constituted only 84.4% of the DARIS of 751 participants. The quality of evidence was low. Incidence of other non-infectious complications: This outcome was not assessed in any included trial.

    AUTHORS' CONCLUSIONS:

    There is no clear evidence for supporting or rejecting the routine use of leukoreduction in all patients requiring PRBC transfusion for preventing TRALI, death, infection, non-infectious complications and other adverse events. As the quality of evidence is very low to low, more evidence is needed before a definitive conclusion can be drawn.

    Source: Leukoreduction for the prevention of adverse reactions from allogeneic blood transfusion. - PubMed - NCBI
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

  2. #2
    PharmD Year 1 TomHsiung's Avatar
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    Default The Diagnosis of TRALI

    The diagnosis of a TRALI reaction is based on the onset of acute lung injury (ALI) within 6 hours of transfusion.ALI is ch aracterized by an acute onset of hypoxemia (oxygen saturation <90% by pulse oximetry for a patient breathing room air or a PaO2/FiO2 ≤300 mmHg), bilateral infiltrates on frontal chest radiograph, and no evidence of circulatory overload.

    Transfusion-Related Acute Lung Injury (TRALI)

    Description and Incidence

    Transfusion-Related Acute Lung Injury (TRALI) is a syndrome characterized by acute respiratory distress following transfusion. All plasma-containing blood products have been implicated including rare reports of IVIG and cryoprecipitate. It is a rare complication of allogeneic blood transfusion but the incidence has not been well established due to difficulty in defining the syndrome and to variable reporting mechanisms worldwide. Various studies have estimated the overall frequency of TRALI to be between 1/1,120 and 1/57,810 units transfused. However, there is wide discrepancy in the literature with the reported frequency is as low as 1/557,000 RBC units and as high as 1/432 platelet units.

    TRALI is associated with a high morbidity with the majority of patients requiring ventilatory support. However, the lung injury is generally transient with PO2 levels returning to pretransfusion levels within 48 -96 hours and CXR returning to normal within 96 hours. TRALI is associated with a significant mortality rate, often approximated at 5 to 10%. Given the gains in safety made within the blood component production industry, particularly with respect to transmission of infectious diseases, TRALI is now among the three leading causes of transfusion related fatalities along with ABO incompatibility and bacterial contamination.

    Definition

    Canadian Blood Services has adopted the definition put forth by the Canadian Consensus Conference Panel on TRALI as outlined below. This definition is applied consistently to all cases of TRALI reported to CBS and is used to determine whether reported cases will be investigated.

    Table 1: Canadian Consensus Conference Panel TRALI definitions
    Term Definition
    TRALI Acute lung injury (defined below) occurring within 6 hours of completion of transfusion of blood component.
    No pre-existing acute lung injury.
    No other temporally associated risk factors for acute lung injury (see below).
    Possible TRALI Acute lung injury (defined below) occurring within 6 hours of completion of transfusion of blood components. No pre-existing acute lung injury. One of more temporally associate risk factors for acute lung injury.

    Table 2: Definition of Acute Lung Injury (ALI)
    Term Definition
    Acute Lung Injury New onset
    Hypoxemia SpO2 <90% or Pa02/Fi02 < 300 mm Hg on room air, or other clinical evidence of hypoxemia
    Bilateral infiltrates on frontal chest X-ray

    Table 3: Risk Factors for Acute Lung Injury
    Direct Lung Injury Indirect Lung Injury
    Aspiration
    Pnuemonia
    Toxic inhalation
    Lung contusion
    Near drowning
    Severe sepsis
    Shock
    Multiple trauma
    Burn injury
    Acute pancreatitis
    Cardiopulmonary bypass
    Drug overdose

    Because the diagnosis of Acute Lung Injury (ALI) can be difficult, it is important for the transfusion service medical director and the patient’s physician to communicate to determine, in particular, whether a patient has evidence of volume overload. Although ALI and hydrostatic pulmonary edema may coexist, the latter is a more common complication of transfusion and must be excluded in order for a diagnosis of TRALI or possible TRALI to be made.

    Source: Transfusion-Related Acute Lung Injury (TRALI) | Transfusion Medicine
    Last edited by TomHsiung; Wed 20th January '16 at 1:02pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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