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Current and Future Alternatives for Allogeneic Blood Product Transfusions
protocol crafted with the input of surgical, haematological, critical care pre-operative oral and/or parenteral iron therapy. In the post-operative
and transfusion physicians may itself serve to limit the use of allogeneic state, patients increase expression of cytokines and other chemical
blood products.
51,52
markers of inflammation due to systemic stressors.
39,54,55
This prolonged
inflammatory state may contribute to the phenomenon of post-
Autologous Blood Donation operative iron-deficiency anaemia.
55,56
Several trials in plastic, colorectal
In preparation for a major invasive surgical procedure, patients may opt and orthopaedic surgery have demonstrated that patients provided
to donate one or more units of autologous whole blood, particularly for with pre-operative doses of either parenteral or oral iron had lower
those procedures where significant blood loss is expected and/or allogeneic blood transfusion requirements in the post-operative
allogeneic transfusion is probable.
40
Unlike the requisite stringent period.
55,57–60
Interestingly, a trial of post-operative intravenous iron
criteria for donation of an allogeneic RBC unit, many patients may plus an erythropoietin-stimulating agent (ESA), with no pre-operative
qualify as autologous RBC donors. According to the American regimen, showed no benefit in recovery of anaemia.
61
Further studies
Association of Blood Banks (AABB), patients eligible for autologous are needed to determine whether parenteral or oral iron therapy may
donation include those with haemoglobin ≥11g/dl or haematocrit be of use pre-operatively in other surgical settings.
≥33%, those donating more than 72 hours pre-operatively and those
without any obvious clinical or laboratory evidence of bacteraemia.
53
Haematopoietic Growth Factors
Some patients, such as Jehovah’s Witnesses, do not accept autologous
units as part of their prohibition against receiving blood. In spite of Erythropoietin-stimulating Agents
more liberal donation criteria, some patients are not candidates for For the anaemic or pre-operative patient, a widely used therapeutic
autologous donation. strategy includes increasing production of endogenous RBCs with
recombinant erythropoietin.
62
The use of ESAs immediately prior to
Despite a reduction in the risk of blood product incompatibility and surgery in otherwise healthy patients likely provides clinical benefit and
transfusion-transmitted diseases, autologous whole blood transfusion reduces post-operative allogeneic RBC transfusion. However, this
is accompanied by its own unique set of drawbacks. Whole blood strategy is of limited utility without the simultaneous provision of iron
autologous units can be used only for oxygen-carrying capacity as by the oral or intravenous route.
40,59,63
ESAs are also commonly used to
platelets and coagulation factors reduce function due to the successfully treat anaemia related to chronic renal disease.
64
A new class of drugs, thrombopoietin-
In recent months, the use of ESAs in lieu of RBC transfusion for anaemia
associated with malignancy has been heavily scrutinised. The most
receptor agonists, has shown
influential study was a phase III clinical trial performed in patients with
promising results for the treatment non-small-cell carcinoma of the lung, which showed decreased patient
of thrombocytopenia in patients
survival following chronic ESA administration.
65
As a result of this and
other earlier cancer-related anaemia trials showing poor patient
with hepatitis C cirrhosis and immune-
outcome with ESA dosing, the FDA issued a ‘black box warning’ for ESA
mediated platelet destruction.
administration.
66–68
In addition to these findings, trials performed in
other anaemic, critically ill patient populations revealed that ESA dosing
temperature and length of storage of the autologous unit. Thus, did not significantly decrease allogeneic RBC transfusion.
69
Furthermore,
patients who develop coagulopathy or thrombocytopenia may require ESA administration was associated with a significant increase in the
some form of allogeneic transfusion. If surgical procedures are incidence of thrombotic events.
69
As more data about the use of ESAs
postponed or autologous blood units not utilised, autologous are collected in clinical trials, appropriate patient population selection
donations are often wasted and can be an inefficient allocation of and criteria are needed in order to guarantee better safety and
healthcare resources.
40
Although autologous units do decrease the risk outcomes with these agents.
of incompatible transfusions and limit infectious disease exposure,
patients receiving autologous units may still be exposed to other risks Platelet- and Leukocyte-stimulating Agents
of transfusion such as septic reactions due to unintentional A new class of drugs, thrombopoietin-receptor agonists, has shown
contamination during unit collection. Febrile transfusion reactions may promising results for the treatment of thrombocytopenia in patients with
also occur due to a lack of leukoreduction of autologous whole blood. hepatitis C cirrhosis and immune-mediated platelet destruction.
70–72
Finally, autologous units may not provide a reasonable alternative to These drugs, such as eltrombopag and AMG 531, appear to stimulate
allogeneic transfusion as recent evidence suggests that those patients megakaryocyte division in the bone marrow, increasing circulating
who donate autologous units are transfused at higher rates compared platelet counts.
70–72
Thrombopoietin-receptor agonists might be
with other populations.
54
Future trials must be performed to determine particularly useful in patient populations who show refractoriness to
the clinical and cost-efficacy of autologous whole blood donation so platelet transfusion. Further studies are currently under way for this
that this technique can be applied to populations where it will be of exciting new class of drugs. The use of recombinant myeloid colony-
greatest benefit. stimulating factors (CSF) such as granulocyte-CSF has also improved care
of patients with severe leukopenia, allowing for increased production of
Parenteral and Oral Iron Administration endogenous myeloid cells.
73
The provision of iron is indicated for patients with severe, clinically
significant iron-deficiency anaemia. However, there is also evidence to Summary
suggest that patients undergoing surgical procedures may benefit from There are many excellent, reliable and safe alternatives to transfusion
EUROPEAN HAEMATOLOGY 2007 35
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