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A meta-analysis of risk factors associated with platelet transfusion refractoriness
Song X, Qi J, Fang K, Li X, Han Y
International journal of hematology. 2023
Abstract
BACKGROUND Platelet transfusion refractoriness (PTR) remains an intractable issue in clinical practice, and is common in hematological patients. At present, it is believed that both immune and non-immune factors play a role. We conducted a meta-analysis of various risk factors which may contribute to PTR. METHODS PubMed, Embase, Cochrane library, and Web of Science were selected as research database platforms. Citations included were further assessed for quality and bias using the Newcastle-Ottawa Scale. All analyses were performed using Review Manager Version 5.4 and STATA 16.0. RESULTS The preliminary search revealed 1069 publications, and 17 (5929 patients in total) were ultimately included in the quantitative analysis. The following variables were associated with the occurrence of PTR: fever (OR = 2.26, 95%CI 2.00-2.55, p < 0.00001), bleeding (OR = 2.10, 95%CI 1.36-3.24, p = 0.0008), female sex (OR = 2.06, 95%CI 1.13-3.75, p = 0.02), antibiotic use (OR = 2.94, 95%CI 1.54-5.59, p = 0.001), and infection (OR = 2.19, 95%CI 1.20-4.03, p = 0.01). Antibodies involved in immune activation were a higher risk factor (OR = 4.17, 95%CI 2.36-7.36, p < 0.00001), and splenomegaly was nearly significant (OR = 1.73, 95%CI 0.97-3.07, p = 0.06). CONCLUSIONS We identified some important risk factors for PTR, but further research is needed to identify the many other possible elements that may contribute to or mediate PTR.
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Quality of evidence-based guidelines for platelet transfusion and use: A systematic review
Al-Riyami AZ, Jug R, La Rocca U, Keshavarz H, Landry D, Shehata N, Stanworth SJ, Nahirniak S
Transfusion. 2021
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Editor's Choice
Abstract
BACKGROUND Guidelines for platelet (PLT) transfusion are an important source of information for clinicians. Although guidelines intend to increase consistency and quality of care, variation in methodology and recommendations may exist that could impact the value of a guideline. We aimed to determine the quality of existing PLT transfusion guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument and to describe the inconsistencies in recommendations. STUDY DESIGN AND METHODS A systematic search was undertaken for evidence-based guidelines from January 1, 2013, to January 25, 2019. Citations were reviewed in duplicate for inclusion and descriptive data extracted. Four physicians appraised the guideline using the AGREE II instrument and the scaled score for each item evaluated was calculated. The protocol was registered in PROSPERO. RESULTS Of 6744 citations, 6740 records were screened. Seven of 28 full-text studies met the inclusion criteria. The median scaled score (and the interquartile range of the scaled score) for the following items were as follows: scope and purpose, 94% (8%); stakeholder involvement, 63% (18%); rigor of development, 83% (14%); clarity of presentation, 94% (6%); applicability, 58% (20%); and editorial independence, 77% (4%). Overall quality ranged from 4 to 7 (7 is the maximum score). Inconsistent recommendations were on prophylactic PLT transfusion in hypoproliferative thrombocytopenia in the presence of risk factors and dose recommendations. CONCLUSION Inconsistencies between guidelines and variable quality highlight areas for future guideline writers to address. Areas of specific attention include issues of stakeholder involvement and applicability.
PICO Summary
Population
Guidelines for platelet (PLT) transfusion (7 studies).
Intervention
Systematic review to determine the quality of existing PLT transfusion guidelines and to describe the inconsistencies in recommendations.
Comparison
Outcome
The median scaled score for the following items were as follows: scope and purpose, 94%; stakeholder involvement, 63%; rigor of development, 83%; clarity of presentation, 94%; applicability, 58%; and editorial independence, 77%. Overall quality ranged from 4 to 7 (7 was the maximum score). Inconsistent recommendations were found on prophylactic PLT transfusion in hypoproliferative thrombocytopenia in the presence of risk factors, and dose recommendations.
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The role of platelet transfusions after intracranial hemorrhage in patients on antiplatelet agents: a systematic review and meta-analysis
Brogi E, Corbella D, Coccolini F, Gamberini E, Russo E, Agnoletti V, Forfori F
World Neurosurg. 2020
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Editor's Choice
Abstract
The current evidence suggests that Antiplatelet agents (APA) slightly increase the risk of death and disease progression in patients with traumatic (TBI) or spontaneous intracranial hemorrhage (ICH). Disappointingly there is little evidence that APA reversal with platelet transfusion (PLT) may improve the outcome. In this systematic review and meta-analysis, our goal was to evaluate the differences in mortality, severe disability, and hematoma expansion related to PLT transfusion. We retrieved randomized, or cohort studies comparing adult patients on APA with TBI or ICH who were treated with PLT or not. We calculated the standardized Risk Difference (RD) and 95% CI. A random-effects model was applied to analyze the data. The heterogeneity of the retrieved trials was evaluated through the I(2) statistic. Our review finally included 16 clinical trials. We observed a significant difference between the two groups only for hematoma expansion: RD was -0.10 (10%; 95% CI: -0.14 to -0.05; P<0.0001; I(2)=0.90) in favor of PLT transfusion. Performing subgroups analyses according to the type of bleeding mechanism, we observed the same results. The use of PLT in patients on APA affected by intracranial hemorrhage seemed to have no clear beneficial effect for the outcomes evaluated; conversely, PLT appeared to slightly increase the odds for adverse events of thromboembolic origin, even though not significantly.
PICO Summary
Population
Adult patients on antiplatelet agents (APA) with traumatic brain injury (TBI) or spontaneous intracranial hemorrhage (ICH), (16 clinical trials).
Intervention
Platelet transfusion (PLT).
Comparison
No platelet transfusion.
Outcome
A significant difference was observed between the two groups only for hematoma expansion: standardized risk difference was -0.10 in favor of PLT transfusion. The same results were observed when performing subgroups analyses according to the type of bleeding mechanism. The use of PLT in patients on APA affected by intracranial hemorrhage seemed to have no clear beneficial effect for the outcomes evaluated; conversely, PLT appeared to slightly increase the odds for adverse events of thromboembolic origin, even though not significantly.
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The effect of platelet transfusion on functional independence and mortality after antiplatelet therapy associated spontaneous intracerebral hemorrhage: A systematic review and meta-analysis
Morris NA, Patel N, Galvagno SM Jr, Ludeman E, Schwartzbauer GT, Pourmand A, Tran QK
Journal of the neurological sciences. 2020;417:117075
Abstract
INTRODUCTION The practice of platelet transfusion to mitigate the deleterious effects of antiplatelet agents on spontaneous intracerebral hemorrhage (ICH) remains common. However, the effect of antiplatelet agents on patients with ICH is still controversial and transfusing platelets is not without risk. We performed a meta-analysis in order to determine the effect of platelet transfusion on antiplatelet agent associated ICH. METHODS We queried PubMed, Embase, and Scopus databases to identify cohort studies, case-control studies, and randomized control trials. Study quality was graded by the Newcastle-Ottawa Scale and Cochrane Risk of Bias tool, as appropriate. Outcomes of interest included functional independence as measured by the modified Rankin Scale and mortality. We compared patients with antiplatelet agent associated ICH who received platelet transfusion to those that did not. RESULTS We identified 625 articles. After reviewing 44 full text articles, 5 were deemed appropriate for meta-analysis, including 4 cohort studies and one randomized control trial. Considerable heterogeneity was present among the studies (I(2) > 81% for all analyses). We did not find a significant effect of platelet transfusions on functional independence (Odds Ratio [OR] 1.3, 95% CI.0.45-3.9) or mortality (OR 0.58, 95% Confidence Interval [CI] 0.12-2.6). CONCLUSION We found no evidence for an effect of platelet transfusions on functional independence or mortality following antiplatelet associated ICH. More randomized trials are needed to evaluate platelet transfusion in patients with ICH and proven reduced platelet activity or those requiring neurosurgical intervention.
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Is platelet transfusion effective in patients taking antiplatelet agents who suffer an intracranial hemorrhage?
Leong LB, David TK
Journal of Emergency Medicine. 2015;49((4)):561-72.
Abstract
BACKGROUND Patients taking antiplatelet agents (APAs) with intracranial hemorrhage (ICH) may be treated with platelet transfusion. OBJECTIVES We conducted a systematic review of the use of platelet transfusion in the management of APA-related ICH. METHODS We searched the Cochrane, Medline, Embase, and CINAHL databases. Included studies were randomized, case-controlled, or cohort studies comparing outcomes in adult patients with APA-related ICH who received or did not receive platelet transfusion. Study quality was measured using appropriate scores. The primary outcome of interest was in-hospital mortality rate. Secondary outcomes included rates of craniotomy, neurological, medical, or radiological deterioration; mean length of hospital stay, delayed mortality, and functional status at discharge. We reported proportions, medians with interquartile ranges, and pooled odds ratios with their 95% confidence intervals. p values < 0.05 were considered statistically significant. RESULTS There were no randomized controlled trials. Seven retrospective cohort studies (four traumatic, three primary ICH) were included. For APA-related traumatic ICH, the pooled odds ratio (OR) for in-hospital mortality with platelet transfusion was 1.77 (95% confidence interval [CI] 1.00-3.13). There were no statistically significant differences for secondary outcomes except for proportion with medical decline (6/44 vs. 2/64; p = 0.006). For APA-related primary ICH, the pooled OR for in-hospital mortality with platelet transfusion was 0.49 (95% CI 0.24-0.98). There were no statistically significant differences for most secondary outcomes between the two groups. These studies had important methodological limitations. CONCLUSIONS The evidence for platelet transfusion in APA-related ICH was inconclusive due to methodological limitations.Copyright © 2015 Elsevier Inc. All rights reserved.
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Platelet transfusion threshold in patients with upper gastrointestinal bleeding: a systematic review
Razzaghi A, Barkun AN
Journal of Clinical Gastroenterology. 2012;46((6):):482-6.
Abstract
BACKGROUND : There exists uncertainty as to the optimal platelet values when managing patients with nonvariceal upper gastrointestinal (GI) bleeding. GOALS AND STUDY A systematic review was carried out to determine the optimal approach when managing patients with thrombocytopenia in the setting of nonvariceal upper GI bleeding. RESULTS : Eighteen of 803 potential articles were selected and reviewed, including 4 randomized controlled trials and 6 cohort studies. The only empirical clinical data available pertained to the management of hematology or oncology patients. There was no high-level evidence that determined the proper threshold of platelet transfusion specifically in GI bleeding. We were, therefore, limited to include principally consensus opinions, recommendations, and guidelines for platelet transfusion trigger as they apply to the treatment (including prophylaxis) of bleeding in general, with a paucity of data addressing major bleeding, let alone bleeding from a gastroenterologic origin. Randomized clinical trials were individually underpowered in allowing definitive conclusions, even though resulting recommendations were supported by similarly underpowered retrospective and prospective observational studies. CONCLUSIONS : There exist a paucity of data to recommend optimal therapeutic platelet count targets in patients with active GI bleeding. Based principally on expert opinion recommendations, we propose a count of 50x10/L. Some professional associations have suggested in very specific clinical settings (postcardiopulmonary bypass surgery or central nervous system trauma) a higher value of up to 100x10/L. Properly designed randomized trials are required to more precisely address this important clinical question.
