In the Journals

Fresh red blood cells no better than older cells for transfusions in critically ill kids

Philip C. Spinella, MD
Philip C. Spinella

Study findings published in JAMA showed no benefit in using fresh red blood cells — cells stored for a maximum of 7 days — over older red blood cells in critically ill pediatric patients receiving transfusion.

“There is now evidence that there is wide variation in how fast red cell function decreases over time from donor to donor,” Philip C. Spinella, MD, director of the critical care translational research program and professor of pediatrics at Washington University School of Medicine in St. Louis, told Healio.

“This concept that storage age of red cells does not accurately reflect quality has led many investigators to search for that quality metric that does reflect optimal ability to deliver oxygen while not causing adverse effects. We all know that people age differently. In retrospect, it is not surprising that our red cells ‘age’ differently when stored in blood banks, too.”

Spinella and colleagues performed an international, blinded, multicenter, randomized clinical trial among patients aged 3 days to 16 years with blood cell transfusions administered within 7 days of ICU admission. The analysis included patients from 50 tertiary care centers and was performed between February 2014 and November 2018, with new or progressive multiple organ dysfunction syndrome as the primary outcome.

Blood transfusion bag 
No significant differences in progressive or new multiple organ dysfunction syndrome were identified between the pediatric patients who received red blood cells stored for 7 days or less and patients who received standard-issue blood.
Source: Adobe Stock

A total of 1,461 patients were included in the final analysis: 728 patients who were given fresh blood cells and 733 who received standard-issue cells, defined as the oldest compatible cells available. Median patient age was 1.8 years, and 47.3% of patients were girls.

No significant differences in progressive or new multiple organ dysfunction syndrome were identified between the fresh (20.2%) and standard-issue (18.2%) groups.

One limitation of the study was that it did not address the safety of transfusing red blood cells stored for 35 to 42 days, Spinella and colleagues noted. The median storage age of red blood cells used in the trial was 18 days.

“Our results are not generalizable to children who predominantly receive the oldest [red blood cells] in inventory,” Spinella said. “It would be optimal to study if older [red blood cells] are harmful, but we are starting to understand that storage age may not be the most accurate indicator of quality. Our results support a recently published hypothesis that the storage age of red cells does not accurately reflect their quality.”

Spinella said some patients may require fresh cells due to extenuating circumstances, such as children who require a transfusion of more than 40ml/kg acutely and patients at risk for hyperkalemia who may require fresh cells due to higher potassium concentrations in cells near their expiration.

Sepsis prevalence was similar between the fresh (25.8%) and standard-issue groups (25.3%), and the prevalence of acute respiratory distress syndrome was 6.6% in the fresh group and 4.8% in the standard-issue group. ICU mortality was 4.5% among patients who received fresh blood and 3.5% in patients who received standard-issue cells (P = .34).

In an accompanying editorial, Zoe K. McQuilten, MBBS, PhD, and D. James Cooper, BMBS, MD, of the Australian and New Zealand Intensive Care Research Centre at Monash University in Melbourne, Australia, wrote that the research “demonstrates the feasibility of large, internationally collaborative randomized trials to address evidence gaps in transfusion medicine involving pediatric patients.” McQuilten and Cooper also wrote that the analysis provides key data to “support the safety of current international transfusion practice in regard to allocation of red blood cells for transfusion in critically ill children.”

“The impact of this trial acutely will be that children’s hospitals may re-think current policies that preferentially use fresh red cells for certain patient populations,” such as infants, patients undergoing cardiac surgery and patients with sickle cell disease, Spinella said. “In the longer term, it will motivate investigators to determine what are the most accurate quality metrics for red cells that reflect efficacy in delivering oxygen and also their safety.” – by Eamon Dreisbach

References:

McQuilten ZK, et al. JAMA. 2019; doi:10.1001/jama.2019.17476.

Spinella PC, et al. JAMA. 2019;doi:10.1001/jama.2019.17478.

Disclosures: Cooper reports receiving grants from the Australian National Health and Medical Research Council (NHMRC), the Health Research Council of New Zealand and the Irish Health Research Board and receiving support from the Australian Red Cross Blood Service, the NHMRC and Eustralis Pharmaceuticals. McQuilten reports receiving funding from the NHMRC and the Australian Red Cross Blood service. Spinella reports serving as a consultant for Hemanext, that his institution received funding for the trial, and to having equity in KaloCyte and receiving grants from KaloCyte, the National Heart, Lung, and Blood Institute and the U.S. Department of Defense. Please see the study for a list of the other authors’ relevant financial disclosures.

Philip C. Spinella, MD
Philip C. Spinella

Study findings published in JAMA showed no benefit in using fresh red blood cells — cells stored for a maximum of 7 days — over older red blood cells in critically ill pediatric patients receiving transfusion.

“There is now evidence that there is wide variation in how fast red cell function decreases over time from donor to donor,” Philip C. Spinella, MD, director of the critical care translational research program and professor of pediatrics at Washington University School of Medicine in St. Louis, told Healio.

“This concept that storage age of red cells does not accurately reflect quality has led many investigators to search for that quality metric that does reflect optimal ability to deliver oxygen while not causing adverse effects. We all know that people age differently. In retrospect, it is not surprising that our red cells ‘age’ differently when stored in blood banks, too.”

Spinella and colleagues performed an international, blinded, multicenter, randomized clinical trial among patients aged 3 days to 16 years with blood cell transfusions administered within 7 days of ICU admission. The analysis included patients from 50 tertiary care centers and was performed between February 2014 and November 2018, with new or progressive multiple organ dysfunction syndrome as the primary outcome.

Blood transfusion bag 
No significant differences in progressive or new multiple organ dysfunction syndrome were identified between the pediatric patients who received red blood cells stored for 7 days or less and patients who received standard-issue blood.
Source: Adobe Stock

A total of 1,461 patients were included in the final analysis: 728 patients who were given fresh blood cells and 733 who received standard-issue cells, defined as the oldest compatible cells available. Median patient age was 1.8 years, and 47.3% of patients were girls.

No significant differences in progressive or new multiple organ dysfunction syndrome were identified between the fresh (20.2%) and standard-issue (18.2%) groups.

One limitation of the study was that it did not address the safety of transfusing red blood cells stored for 35 to 42 days, Spinella and colleagues noted. The median storage age of red blood cells used in the trial was 18 days.

“Our results are not generalizable to children who predominantly receive the oldest [red blood cells] in inventory,” Spinella said. “It would be optimal to study if older [red blood cells] are harmful, but we are starting to understand that storage age may not be the most accurate indicator of quality. Our results support a recently published hypothesis that the storage age of red cells does not accurately reflect their quality.”

Spinella said some patients may require fresh cells due to extenuating circumstances, such as children who require a transfusion of more than 40ml/kg acutely and patients at risk for hyperkalemia who may require fresh cells due to higher potassium concentrations in cells near their expiration.

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Sepsis prevalence was similar between the fresh (25.8%) and standard-issue groups (25.3%), and the prevalence of acute respiratory distress syndrome was 6.6% in the fresh group and 4.8% in the standard-issue group. ICU mortality was 4.5% among patients who received fresh blood and 3.5% in patients who received standard-issue cells (P = .34).

In an accompanying editorial, Zoe K. McQuilten, MBBS, PhD, and D. James Cooper, BMBS, MD, of the Australian and New Zealand Intensive Care Research Centre at Monash University in Melbourne, Australia, wrote that the research “demonstrates the feasibility of large, internationally collaborative randomized trials to address evidence gaps in transfusion medicine involving pediatric patients.” McQuilten and Cooper also wrote that the analysis provides key data to “support the safety of current international transfusion practice in regard to allocation of red blood cells for transfusion in critically ill children.”

“The impact of this trial acutely will be that children’s hospitals may re-think current policies that preferentially use fresh red cells for certain patient populations,” such as infants, patients undergoing cardiac surgery and patients with sickle cell disease, Spinella said. “In the longer term, it will motivate investigators to determine what are the most accurate quality metrics for red cells that reflect efficacy in delivering oxygen and also their safety.” – by Eamon Dreisbach

References:

McQuilten ZK, et al. JAMA. 2019; doi:10.1001/jama.2019.17476.

Spinella PC, et al. JAMA. 2019;doi:10.1001/jama.2019.17478.

Disclosures: Cooper reports receiving grants from the Australian National Health and Medical Research Council (NHMRC), the Health Research Council of New Zealand and the Irish Health Research Board and receiving support from the Australian Red Cross Blood Service, the NHMRC and Eustralis Pharmaceuticals. McQuilten reports receiving funding from the NHMRC and the Australian Red Cross Blood service. Spinella reports serving as a consultant for Hemanext, that his institution received funding for the trial, and to having equity in KaloCyte and receiving grants from KaloCyte, the National Heart, Lung, and Blood Institute and the U.S. Department of Defense. Please see the study for a list of the other authors’ relevant financial disclosures.