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Platelet transfusion refractoriness

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Platelet transfusion refractoriness is the repeated failure to achieve the desired level of blood platelets in a patient following a platelet transfusion. The cause of refractoriness may be either immune or nonimmune based. Among immune-related refractoriness, antibodies against HLA antigens are the primary cause. Non-immune causes include splenomegaly (enlargement of the spleen), fever, and sepsis.[1][2]

Cause

Platelet refractoriness can be due to immune causes or non-immune causes.[3] Non-immune causes account for over 80% of cases of platelet refractoriness, and sepsis is one of the most common non-immune causes.[2][3][4][5] HLA alloimmunization is the commonest immune cause of platelet refractoriness.[2][3][4][5]

Non-immune causes

  • Fever
  • Treatment of infection, antibiotics (vancomycin), antifungals (amphotericin B)
  • Bleeding

Immune causes

  • Other antibodies
    • Drug-related antibodies

Diagnosis

Platelet transfusion refractoriness can be defined in several different ways. All measures of platelet refractoriness are defined by the timing of the post-transfusion platelet count, usually 1 hour post transfusion or 24 hours post transfusion or both.[2][6]

Platelet increment (PI)

This is the simplest method, and only requires data on the platelet count before and after the transfusion.[6] The platelet increment is also known as the absolute count increment and count increment.[7][5]

PI = post-transfusion platelet count - pre-transfusion platelet count

However, it is affected by the number of platelets given in the transfusion (platelet dose) and the patient’s blood volume. Larger patients and smaller platelet doses decrease the platelet increment.[2][6] These factors are adjusted for in the other methods of defining platelet refractoriness.[2][3][6]

A 1 hour post-transfusion PI of less than 5 to 10 x 109/l is considered evidence of platelet refractoriness.[5][7] Due to lack of data on platelet dose this is often the only measure of platelet refractoriness that can be performed in routine clinical practice.[5]

Percentage platelet recovery (PPR)

Requires data on the platelet increment (PI), the patient’s total blood volume (TBV) - estimated using the patient’s weight multiplied by 0.075, and the number of platelets transfused (platelet dose)[8][7]

PPR = ((PI x TBV)/PD) x 100

At 1 hour post-transfusion, a PPR < 20% is considered evidence of platelet refractoriness.[5][7] At 16 hours post-transfusion a PPR < 10% is considered evidence of platelet refractoriness.[7]

Percentage platelet increment (PPI)

PPI is very similar to the percentage platelet recovery (PPR) but the patient’s total blood volume is estimated using the patient’s weight multiplied by 0.07, and there has been an additional adjustment for splenic pooling of platelets (multiplied by 2/3)[8][5]

PPI = ((PI x TBV x 0.67)/PD) x 100

Corrected count increment (CCI)

This requires data on the platelet increment (PI), the patient’s Body surface area (BSA), and the number of platelets transfused (PD).[8][5][7]

CCI = ((PI x BSA)/PD

At 1 hour post-transfusion a CCI greater than 7500 indicates a sufficient post-transfusion increment, whereas a CCI less than 7500 is considered diagnostic of platelet refractoriness.[7] At 24 hours post transfusion a CCI less than 5000 suggests platelet refractoriness.[7]

Platelet dose

Some blood banks maintain records of the estimated number of platelets in each unit.[5] Current requirements in the US stipulate that a unit of apheresis platelets must contain at least 3.0 x1011 platelets.[9] In England only 1% of adult platelet components are tested to check the number of platelets meet the minimum required standard of 2.4 x 1011 platelets. [10][11] Only components that contain fewer than 1.6 x 1011 platelets are discarded.[10][11] This means that there can be a lot of variability in the number of platelets contained within each transfusion.[5]



Immune-mediated refractoriness usually shows little or no increment in the immediate post-transfusion platelet count. Non-immune refractoriness may show an initial rise in platelet count, but a subsequent 8-hour or 12-hour post-transfusion sample shows a return to the baseline platelet count.[citation needed]

References

  1. ^ Colman, Robert W.; Marder, Victor J.; Clowes, Alexander W.; George, James N.; Goldhaber, Samuel Z. (2005), Hemostasis and Thrombosis: Basic Principles and Clinical Practice (5th ed.), Lippincott Williams & Wilkins, p. 1195, ISBN 0-7817-4996-4
  2. ^ a b c d e f Stanworth, Simon J.; Navarrete, Cristina; Estcourt, Lise; Marsh, Judith (2015). "Platelet refractoriness – practical approaches and ongoing dilemmas in patient management". British Journal of Haematology. 171 (3): 297–305. doi:10.1111/bjh.13597. ISSN 1365-2141.
  3. ^ a b c d "Guidelines for the management of platelet transfusion refractoriness" (PDF). hospital.blood.co.uk. Retrieved 2018-12-28. {{cite web}}: Cite has empty unknown parameter: |dead-url= (help)
  4. ^ a b "transfusion.com.au". transfusion.com.au. Retrieved 2018-12-28.
  5. ^ a b c d e f g h i j Hod, Eldad; Schwartz, Joseph (2008). "Platelet transfusion refractoriness". British Journal of Haematology. 142 (3): 348–360. doi:10.1111/j.1365-2141.2008.07189.x. ISSN 1365-2141.
  6. ^ a b c d Rebulla, Paolo (2005-2). "A mini-review on platelet refractoriness". Haematologica. 90 (2): 247–253. ISSN 1592-8721. PMID 15710579. {{cite journal}}: Check date values in: |date= (help)
  7. ^ a b c d e f g h Pavenski, Katerina; Freedman, John; Semple, J. W. (2012-4). "HLA alloimmunization against platelet transfusions: pathophysiology, significance, prevention and management". Tissue Antigens. 79 (4): 237–245. doi:10.1111/j.1399-0039.2012.01852.x. ISSN 1399-0039. PMID 22385314. {{cite journal}}: Check date values in: |date= (help)
  8. ^ a b c Rebulla, P. (1993). "Formulae for the definition of refractoriness to platelet transfusion". Transfusion Medicine. 3 (1): 91–92. doi:10.1111/j.1365-3148.1993.tb00108.x. ISSN 1365-3148.
  9. ^ AABB (2014). Standards for Blood Banks and Transfusion Services. AABB. ISBN 9781563958878.
  10. ^ a b "Platelets, Apheresis, Leucocyte Depleted". www.transfusionguidelines.org. Retrieved 2018-12-29.
  11. ^ a b "Platelets, Pooled, Buffy Coat Derived, in Additive Solution and Plasma, Leucocyte Depleted". www.transfusionguidelines.org. Retrieved 2018-12-29. {{cite web}}: no-break space character in |title= at position 82 (help)


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