Until recovery of bone marrow function, pediatric hematopoietic stem cell transplant (HSCT) patients are dependent on prophylactic red blood cell (RBC) and platelet transfusions to avoid the complications associated with anemia and thrombocytopenia. Current transfusion thresholds represent a balance between the risks of transfusion and the risks of anemia and bleeding. There has never been a prospective randomized, controlled trial to evaluate optimal transfusion practices in pediatric patients with prolonged hypo-proliferative anemia and thrombocytopenia. In the absence of specific evidence-based guidelines, there are a variety of clinical practices. This survey was designed to ascertain current transfusion practices in pediatric HSCT patients: both standard prophylactic thresholds as well as clinical circumstances that lead to the change in these thresholds. We hypothesized that there would be variation in transfusion practices for both red blood cells and platelets among pediatric stem cell transplant centers.
Individual directors of pediatric stem cell transplant programs were identified through the Children's Oncology Group member roster (n=83) and were invited via email to participate in a web-based survey (Surveymonkey.com, LLC) regarding the transfusion practices in pediatric HSCT patients at their institutions. A total of 57 individuals responded to the survey for a response rate of 69%.
Of the 57 respondents, 95% reported having transfusion thresholds for platelet and RBC transfusions. The hemoglobin thresholds that prompted RBC transfusion ranged from 6–10 g/dl; 62% of institutions reported using 8 g/dl, 26% used ≤ 7 g/dl, 12% used ≥ 8.5 g/dl. Respondents were asked about five hypothetical clinical scenarios under which they would change a patient's RBC threshold. The percent of respondents who would increase a patient's threshold is given in parentheses: hypoxia (94%), cardiac disease (75.5%), sepsis (64%), patient comfort (56.6%), and fever (15.4%). Additional reasons to increase RBC threshold included active bleeding, transplant for hemoglobinopathy, or serious illness (i.e., on a ventilator or continuous veno-venous hemodialysis).
For platelet transfusion thresholds, respondents were evenly split between using a platelet count of 10 × 109/L and 20 × 109/L (44% and 47%, respectively). A minority of institutions had no threshold (4%) and the remainder used 15 × 109/L. Clinical scenarios that would prompt an increase in platelet transfusion threshold included hematuria (100%), grade III/IV mucositis (56.4%), sepsis (50.9%), and fever (25.5%). Additional situations suggested by respondents included active bleeding, sickle cell disease, persistent CNS tumor, and on anticoagulation therapy.
There was no correlation between the number of transplants performed per year at an institution and the thresholds used for RBC and platelet transfusions. Also, institutions that had a transfusion threshold of 7 g/dl for RBC transfusions were slightly more likely to have the lower platelet threshold of 10 × 109/L than 20 × 109/L (60% versus 40%, respectively). Institutions that used 8 g/dl were more evenly split with regards to platelet transfusion threshold: 47% used 10 × 109/L and 53% used 20 × 109/L.
There is a paucity of evidence-based transfusion guidelines in pediatric HSCT patients and this survey was designed to evaluate what RBC and platelet transfusion thresholds are currently being used in practice. These data demonstrate equipoise between the different transfusion strategies, which is important in the design of prospective randomized, controlled trials to evaluate the optimal RBC and platelet transfusion thresholds in these patients. Future directions for research include establishing evidence-based transfusion guidelines for both uncomplicated pediatric HSCT patients as well as those with common post-transplant complications.
No relevant conflicts of interest to declare.
Asterisk with author names denotes non-ASH members.