Prolonged Blood Storage and Risk of Posttransfusion Acute Kidney Injury
Adegboye J, Sapatnekar S, Mascha EJ, Shah K, Lioudis M, Essber H, Cohen B, Rivas E, Heddle NM, Eikelboom JW, et al
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BACKGROUND Erythrocyte transfusions are independently associated with acute kidney injury. Kidney injury may be consequent to the progressive hematologic changes that develop during storage. This study therefore tested the hypothesis that prolonged erythrocyte storage increases posttransfusion acute kidney injury. METHODS The Informing Fresh versus Old Red Cell Management (INFORM) trial randomized 31,497 patients to receive either the freshest or oldest available matching erythrocyte units and showed comparable mortality with both. This a priori substudy compared the incidence of posttransfusion acute kidney injury in the randomized groups. Acute kidney injury was defined by the creatinine component of the Kidney Disease: Improving Global Outcomes criteria. RESULTS The 14,461 patients included in this substudy received 40,077 erythrocyte units. For patients who received more than one unit, the mean age of the blood units was used as the exposure. The median of the mean age of blood units transfused per patient was 11 days [interquartile range, 8, 15] in the freshest available blood group and 23 days [interquartile range, 17, 30] in the oldest available blood group. In the primary analysis, posttransfusion acute kidney injury was observed in 688 of 4,777 (14.4%) patients given the freshest available blood and 1,487 of 9,684 (15.4%) patients given the oldest available blood, with an estimated relative risk (95% CI) of 0.94 (0.86 to 1.02; P = 0.132). The secondary analysis treated blood age as a continuous variable (defined as duration of storage in days), with an estimated relative risk (95% CI) of 1.00 (0.96 to 1.04; P = 0.978) for a 10-day increase in the mean age of erythrocyte units. CONCLUSIONS In a population of patients without severely impaired baseline renal function receiving fewer than 10 erythrocyte units, duration of blood storage had no effect on the incidence of posttransfusion acute kidney injury.
Hospitalized patients enrolled across four countries in the Informing Fresh versus Old Red Cell Management (INFORM) trial (n= 14,461).
Transfusion with freshest available erythrocyte units (n= 4,777).
Transfusion with oldest available erythrocyte units (n= 9,684).
The median of the mean age of blood units transfused per patient was 11 days in the freshest available blood group and 23 days in the oldest available blood group. In the primary analysis, post-transfusion acute kidney injury was observed in 688 of 4,777 (14.4%) patients given the freshest available blood and 1,487 of 9,684 (15.4%) patients given the oldest available blood, with an estimated relative risk of 0.94.
Effect of transfusion of washed red blood cells on serumpotassium level in hemodialysis patients
Demirtunc R, Ustun E, Karatoprak C, Kayatas K, Cetinkaya F, Ozensoy U, Kazancioglu R
Turkish Journal of Medical Sciences. 2017;47((2)):407-411.
BACKGROUND/AIM: This study aimed to compare washed red blood cell (WRBC) transfusion versus nonwashed RBC (NWRBC) transfusion in terms of posttransfusion potassium levels in dialysis patients on a day when the patient did not receive dialysis. MATERIALS AND METHODS The patients were randomly assigned into two groups, i.e. those receiving WRBCs (n = 21) and those receiving NWRBCs (n = 17). Both groups received one unit of RBCs. Serum potassium and sodium levels were measured before and at the 1st, 2nd, 3rd, 4th, and 6th hours after transfusion. RESULTS In the WRBC group, the changes in the serum potassium levels at the 3rd, 4th, and 6th hours after transfusion were significant compared with pretransfusion levels. In the serum potassium levels mean decreases by 0.38 +/- 0.57 mEq/L at the 3rd hour (P = 0.006), by 0.32 +/- 0.47 mEq/L at the 4th hour (P = 0.005), and by 0.32 +/- 0.51 mEq/L at the 6th hour (P = 0.009) after transfusion were significant compared with the pretransfusion levels. CONCLUSION Although nonwashed RBC transfusion does not change serum potassium levels, washed RBC transfusion significantly reduces serum potassium levels. Washed RBC transfusion is considered to be safer in hemodialysis patients with hyperkalemia and anemia.
Epidemiology of RBC transfusions in patients with severe acute kidney injury: analysis from the Randomized Evaluation of Normal Versus Augmented Level Study
Bellomo R, Martensson J, Kaukonen KM, Lo S, Gallagher M, Cass A, Myburgh J, Finfer S, Randomized Evaluation of Normal Versus Augmented Level of Replacement Therapy Study Investigators
Critical Care Medicine. 2016;44((5)):892-900.
OBJECTIVE To assess the epidemiology and outcomes associated with RBC transfusion in patients with severe acute kidney injury requiring continuous renal replacement therapy. DESIGN Post hoc analysis of data from a multicenter, randomized, controlled trial. SETTING Thirty-five ICUs in Australia and New Zealand. PATIENTS Cohort of 1,465 patients enrolled in the Randomized Evaluation of Normal versus Augmented Level replacement therapy study. INTERVENTIONS Daily information on morning hemoglobin level and amount of RBC transfused were prospectively collected in the Randomized Evaluation of Normal versus Augmented Level study. We analyzed the epidemiology of such transfusions and their association with clinical outcomes. MEASUREMENTS AND MAIN RESULTS Overall, 977 patients(66.7%) received a total of 1,192 RBC units. By day 5, 785 of 977 transfused patients (80.4%) had received at least one RBC transfusion. Hemoglobin at randomization was lower in transfused than in nontransfused patients (94 vs 111g/L; p < 0.001). Mean daily hemoglobin was 88+/-7 and 99+/-12g/L in transfused and nontransfused patients. Among transfused patients, 228 (46.7%) had died by day 90 when compared with 426 (43.6%) of nontransfused patients (p = 0.27). Survivors received on average 316+/-261mL of RBC, whereas nonsurvivors received 302+/-362mL (p = 0.42). On multivariate Cox regression analysis, RBC transfusion was independently associated with lower 90-day mortality (hazard ratio, 0.55; 95% CI, 0.38-0.79). However, we found no independent association between RBC transfusions and mortality when the analyses were restricted to patients surviving at least 5 days (hazard ratio, 1.29; 95% CI, 0.90-1.85). We found no independent association between RBC transfusion and renal replacement therapy-free days, mechanical ventilator-free days, or length of stay in ICU or hospital. CONCLUSIONS In patients with severe acute kidney injury treated with continuous renal replacement therapy, we found no association of RBC transfusion with 90-day mortality or other patient-centered outcomes. The optimal hemoglobin threshold for RBC transfusion in such patients needs to be determined in future randomized controlled trials.
Role of preoperative donor-specific transfusion and cyclosporine in haplo-identical living related renal transplant recipients
Sharma RK, Rai PK, Kumar A, Kumar P, Gupta A, Kher V, Agrawal S, Bhandari M
A prospective randomized trial of use of donor-specific transfusion and cyclosporine given 24 h before operation was performed in living related renal transplant recipients. The benefits, disadvantages and effect on graft and patient outcome was analyzed. Cyclosporine was started 72 h before operation and 48 h before donor-specific transfusion (DST). Fifteen patients received DST while another 15 age- and sex-matched living related renal allograft recipients on similar immunosuppression served as controls. Patient and donor demographics were similar in the two groups. The DST group had significantly fewer rejection episodes than the control group (0.26 vs. 1.1 rejection episode per patient, p < 0.01). There were fewer episodes of acute rejection in the first 3 months posttransplant in the DST group. Hyperresponder recipients (as tested by mixed lymphocyte cultures) also benefitted by DST which significantly reduced the number of acute rejection episodes (0.25 vs. 1 episode per hyperresponder patient, DST vs. control, p < 0.05). The need for dialysis, incidence of infections and other complications were similar in the two groups. Graft function at 3, 6, 9 and 12 months after transplant was significantly better in the DST group (p < 0.05). Graft survival at 1 year in DST group (85.5%) was not statistically different than control (74.8%). In conclusion, DST and cyclosporine given 24 h before live related renal transplantation is effective in improving graft function and reducing the number of acute rejection episodes which could have a beneficial effect on long-term graft survival.
A randomized study comparing leukocyte-depleted versus packed red cell transfusions in prospective cadaver renal allograft recipients
Sanfilippo FP, Bollinger RR, MacQueen JM, Brooks BJ, Koepke JA
A prospective randomized study at a single renal transplant center between 1980 and 1982 compared the influence of leukocyte-depleted versus packed red cell pretransplantation blood transfusions on patient sensitization to leukocyte (HLA) antigens, likelihood of receiving a graft, and eventual transplantation results. All consenting potential cadaver renal transplant recipients (n = 107) were randomly assigned to receive transfusions at 6-week intervals with either packed red cells (Group 1) or leukocyte-poor red cells (Group 2) until they were transplanted. Actuarial graft and patient survival were identical for graft recipients in both groups. Although the likelihood of receiving a graft was associated with the level of pretransplant sensitization to leukocyte (HLA) antigens (p less than 0.02) as measured by the percent of panel reactive antibody (PRA), it was not associated with the type of blood used. The highest mean peak reactive PRA level for all patients showed a low but significant increase (29 +/- 4 versus 43 +/- 5%; p less than 0.0005) following entry into the transfusion protocol, but the rate of increase was the same for patients in both treatment groups. The likelihood of receiving a transplant was primarily associated with a history of prior graft rejection (p less than 0.05), and patients with prior graft loss had the greatest increase in sensitization following entry into the transfusion protocol. These findings indicate that using leukocyte-poor red cells for pretransplant transfusions provided no added benefit when compared with packed red cells in terms of patient sensitization, the likelihood of receiving a transplant, or eventual graft survival.
Peroperative blood-transfusion improve cadaveric renal-allograft survival in non-transfused recipients. A prospective controlled clinical trial
Williams KA, Ting A, French ME, Oliver D, Morris PJ
The effect of peroperative transfusion was studied in 27 patients who had never had a blood-transfusion or been pregnant and who were receiving their first cadaver renal allograft. 13 patients in the treatment group were given 2 units of whole stored blood at transplantation, whereas 14 patients in the control group were given no blood. Actuarial analysis after 2 years showed a graft survival of 85% at 1 year in the treated group compared with 34% at 1 year in the control group (p = 0.03). Transfusion of non-transfused patients during transplantation may be as effective as pregraft transfusion.