Hyperkalaemia Following Blood Transfusion-a Systematic Review Assessing Evidence and Risks
Transfusion medicine reviews. 2022
Hyperkalaemia following transfusion is widely reported in the literature. Our objective was to critically review recent evidence on hyperkalaemia in association with transfusion and to assess whether specific aspects of transfusion practice can affect the likelihood of developing hyperkalaemia. We searched 9 electronic databases (including MEDLINE, Embase, and Transfusion Evidence Library) using a predefined search strategy, from 2010 to April 8, 2021. Three reviewers performed dual screening, extraction, and risk of bias assessment. We used Cochrane risk of bias (ROB) 2 for assessment of RCTs, ROBINS-I for non-RCTs, and GRADE to assess the certainty of the evidence. We report 7 comparisons of interest in n = 3729 patients from 28 studies (11 RCTs, 4 prospective cohort studies, and 13 retrospective cohort studies): (1) age of blood, (2) washing, (3) filtration, (4) irradiation, (5) fluid type, (6) transfusion vs no transfusion, (7) blood volume/rate. Of the 28 studies included, 25 reported outcomes of potassium (K+) concentration, 17 the number developing hyperkalaemia, 13 mortality, 10 cardiac arrest, and 10 cardiac arrhythmia. Only 16 studies provided analysable data suitable for quantitative analysis. Evidence addressing our outcomes was of very low certainty (downgraded for incomplete outcome data, baseline imbalance, imprecision around the estimate, and small sample size). While 5 studies showed a difference in K+ concentration up to 6 hours posttransfusion for 3 comparisons (age of blood, washing, and transfusion volume/rate), and 3 studies showed a difference in the diagnosis of hyperkalaemia for 2 comparisons (age of blood, and transfusion volume/rate), the evidence was inconsistent across all included studies. There was no difference in any reported outcomes for 4 comparisons (filtration, irradiation, fluid type, or transfusion vs no transfusion). Overall, the reported evidence was too weak to support identification of groups most at risk of hyperkalaemia or to support recommendations on use of short-storage RBC. For other commonly used risk mitigations for hyperkalaemia in transfusion medicine, the (low certainty) evidence was either conflicting or not supportive.
Effects of the COVID-19 pandemic on supply and use of blood for transfusion
Neonates, children, and adults receiving red blood cell transfusions (28 studies, n= 3,729).
To systematically review hyperkalaemia in association with transfusion and to assess whether specific aspects of transfusion practice can affect the likelihood of developing hyperkalaemia.
25 studies reported outcomes of potassium (K+) concentration, 17 the number developing hyperkalaemia, 13 mortality, 10 cardiac arrest, and 10 cardiac arrhythmia. While 5 studies showed a difference in K+ concentration up to 6 hours post-transfusion for age of blood, washing, and transfusion volume/rate, and 3 studies showed a difference in the diagnosis of hyperkalaemia for age of blood, and transfusion volume/rate, the evidence was inconsistent across all included studies. There was no difference in any reported outcomes for filtration, irradiation, fluid type, or transfusion vs. no transfusion. Overall, the reported evidence was too weak to support identification of groups most at risk of hyperkalaemia or to support recommendations on use of short-storage red blood cells.
Lancet Haematol. 2020
The COVID-19 pandemic has major implications for blood transfusion. There are uncertain patterns of demand, and transfusion institutions need to plan for reductions in donations and loss of crucial staff because of sickness and public health restrictions. We systematically searched for relevant studies addressing the transfusion chain-from donor, through collection and processing, to patients-to provide a synthesis of the published literature and guidance during times of potential or actual shortage. A reduction in donor numbers has largely been matched by reductions in demand for transfusion. Contingency planning includes prioritisation policies for patients in the event of predicted shortage. A range of strategies maintain ongoing equitable access to blood for transfusion during the pandemic, in addition to providing new therapies such as convalescent plasma. Sharing experience and developing expert consensus on the basis of evolving publications will help transfusion services and hospitals in countries at different stages in the pandemic.
Randomized trial of red cell washing for the prevention of transfusion-associated organ injury in cardiac surgery
British Journal of Anaesthesia. 2017;118((5):):689-698
Background.: Experimental studies suggest that mechanical cell washing to remove pro-inflammatory components that accumulate in the supernatant of stored donor red blood cells (RBCs) might reduce inflammation and organ injury in transfused patients. Methods.: Cardiac surgery patients at increased risk of large-volume RBC transfusion were eligible. Participants were randomized to receive either mechanically washed allogenic RBCs or standard care RBCs. The primary outcome was serum interleukin-8 measured at baseline and at four postsurgery time points. A mechanism substudy evaluated the effects of washing on stored RBCs in vitro and on markers of platelet, leucocyte, and endothelial activation in trial subjects. Results.: Sixty adult cardiac surgery patients at three UK cardiac centres were enrolled between September 2013 and March 2015. Subjects received a median of 3.5 (interquartile range 2-5.5) RBC units, stored for a mean of 21 ( sd 5.2) days, within 48 h of surgery. Mechanical washing reduced concentrations of RBC-derived microvesicles but increased cell-free haemoglobin concentrations in RBC supernatant relative to standard care RBC supernatant. There was no difference between groups with respect to perioperative serum interleukin-8 values [adjusted mean difference 0.239 (95% confidence intervals -0.231, 0.709), P =0.318] or concentrations of plasma RBC microvesicles, platelet and leucocyte activation, plasma cell-free haemoglobin, endothelial activation, or biomarkers of heart, lung, or kidney injury. Conclusions.: These results do not support a hypothesis that allogenic red blood cell washing has clinical benefits in cardiac surgery. Clinical trial registration.: ISRCTN 27076315.
What is the maximum time that a unit of red blood cells can be safely left out of controlled temperature storage?
Transfusion Medicine Reviews. 2012;26((3):):209-223.e3.
The objective of this systematic review was to identify and analyze the evidence base supporting the 30-minuteand 4-hourrules in transfusion medicine. The 30-minute rule states that red blood cell (RBC) units left out of controlled temperature storage for more than 30 minutes should not be returned to storage for reissue; the 4-hour rule states that transfusion of RBC units should be completed within 4 hours of their removal from controlled temperature storage. Eligible studies were identified from searches (to October 2010) of a range of electronic databases (including The Cochrane Library, MEDLINE, EMBASE, and the National Health Service Blood and Transplant's Transfusion Evidence Library) and contact with transfusion medicine and blood bank experts. Twenty-three studies were identified that measured the quality of the RBC unit (n = 19), bacterial contamination in the RBC unit (n = 4), or both (n = 2) after exposure to greater than 4degreesC +/- 2degreesC from between 20 minutes to 42 days. The overall finding was that temperature exposure did not adversely affect the quality of the RBC units or result in significant bacterial contamination. However, the variation in the temperature of exposure, its duration, the amount of data reported by the individual studies, and the age of the studies (and thus their comparability to current clinical practice) make it difficult to draw significant conclusions. To reliably determine whether these time rulescould be extended without an adverse risk to the RBC unit requires robust, modern studies using multiple combinations of blood, anticoagulant, and additive solutions with defined temperatures and times of exposure. Crown Copyright Copyright 2012. Published by Elsevier Inc. All rights reserved.