Do we really need fresh blood?

In India the demand for fresh blood units  especially in case of cardiac surgeries has been a major challenge for the voluntary blood donation program. Though vast majority of associated clinicians agree that there is no need for so called fresh blood units  but still the hospitals involved in cardiac surgeries continue to demand 'fresh' units.  In such scenarios the blood available off the shelf coming from voluntary blood donors becomes useless for the patient. This also encourages the practice of replacement blood donation. 

The trauma that families often suffer when they are asked to organise for 4-6 donors before cardiac surgeries also has a severe damaging effect on the confidence they share about the voluntary blood donation movement. They in-turn give a negative feedback about blood banking to their peers and family members asking people to donate blood only when a patient needs it  thus derailing the entire blood donation movement. Sankalp India Foundation often faces difficult questions from camp organisers who ask why they should organise for replacement blood donors in-spite of having donated hundreds of units of blood in regular drives. 

The patients who travel to large cities for cardiac cities and the poor patients suffer the most. They need to undergo the process of convincing people to leave their work and come to donate blood for their patients. The rationales behind maintaining anonymity between donor and recipient and truly voluntary blood donation are compromised in the worst possible way when the patients are forced to organise for donors!

Let us try to examine the latest evidence associated with the advantages of fresh blood over blood units stored for a longer time. So far, there is missed evidence mostly originating from observational studies. Fortunately, large scale randomised multi-centre trials are underway and the results are now coming out. AABB's Transfusion News has shared 2 recent studies one involving premature infants (Age of Red Blood Cells in Premature Infants trial - ARIPI) and the other involving cardiac surgery patients (Red Cell Storage Duration Study, also known as RECESS). These two cohorts of patients clearly show no advantage of fresh units over stored units. Trials are underway for other cohorts of patients as well. This should finally put an end to the debate.

We are sharing the two articles “as is”.
Older Red Blood Cells are Not Associated with Adverse Outcomes in Transfused Cardiac Surgery Patients
Today we'll be discussing the age of red blood cells and the impact on clinical outcomes in cardiac surgery patients. These data were presented at the AABB annual meeting plenary session. Over time, red bloods cells undergo morphological and biochemical changes that may decrease their oxygen-carrying capacity. However, it is unclear whether these changes actually affect patient outcomes.

Dr. Triulzi from the University of Pittsburgh comments:
“There has been a large body of observational studies that have been published looking at the effects of red cell storage on clinical outcomes in various patient groups including cardiac surgery, trauma, ICU patients and pediatric patients. The results of these studies are mixed with some studies showing that longer stored blood was associated with worse outcomes and other studies not showing any difference.”

The results of randomized trials should help to answer this question. The ARIPI trial of premature infants, found no difference in patient outcomes for those receiving fresh red blood cells compared to those receiving standard of care.

New data from the NHLBI-supported Red Cell Storage Duration Study, also known as RECESS, are now available. This randomized controlled trial, conducted at 33 medical centers in the United States over four years, evaluated the effect of red blood cell storage time in transfused cardiac surgery patients. Patients were randomized to receive either leukoreduced red blood cells stored for 10 days or less or red cells stored for 21 days or more. The primary outcome was the change in the multi-organ dysfunction score through day 7 and secondary end points including changes in multi-organ dysfunction score through day 28, serious adverse events and mortality at 28 days post surgery.

Dr. Triulzi summarizes the implications of the RECESS trial:
“This is the first randomized clinical trial looking at the storage age of blood in patients undergoing complex cardiac surgery procedures, and we can say with confidence that we did not see differences in changes in multiorgan dysfunction scores, serious adverse events or mortality at day 28 in patients who were transfused with leukoreduced red blood cells that were stored for longer or shorter periods. There are other ongoing clinical trials in other patient groups such as ICU patients that will answer this question in those patient populations.”

1.    Fergusson DA, Hebert P, Hogan DL, LeBel L, Rouvinez-Bouali N, Smyth JA, Sankaran K, Tinmouth A, Blajchman MA, Kovacs L, Lachance C, Lee S, Walker CR, Hutton B, Ducharme R, Balchin K, Ramsay T, Ford JC, Kakadekar A, Ramesh K, Shapiro S. Effect of fresh red blood cell transfusions on clinical outcomes in premature, very low-birth-weight infants: the ARIPI randomized trial. JAMA 2012;308: 1443-51.

2.    Steiner ME, Assmann SF, Levy JH, Marshall J, Pulkrabek S, Sloan SR, Triulzi D, Stowell CP. Addressing the question of the effect of RBC storage on clinical outcomes: the Red Cell Storage Duration Study (RECESS) (Section 7). Transfus Apher Sci 2010;43: 107-16.

3.    Steiner ME, Triulzi D, Assmann SF, Sloan SR, Delaney M, Blajchman MA, Granger S, D'Andrea PA, Pulkrabek S, Stowell CP. Randomized Trial Results: Red Cell Storage Age is Not Associated with a Significant Difference in Multiple-Organ Dysfunction Score or Mortality in Transfused Cardiac Surgery Patients. Transfusion 2014;54 Supplement: 15A.

Date Posted: October 30, 2014
Source: Transfusion News

Randomized Trial Demonstrates No Benefit of Fresh Red Cells for Transfusion
Red blood cells, or RBCs, are routinely used in the transfusion of ill patients to deliver oxygen to tissues. Additive solutions, special containers, and processing procedures permit red cells to have an extended shelf-life. This allows transfusion services to maintain adequate supplies of blood products for patients with different blood types and transfusion needs. On average, RBC units are stored for two or three weeks before transfusion.

RBCs stored over time have altered deformability, and morphologic and biochemical changes which decrease oxygen-carrying capacity and may reduce red cell survival. Observational studies have suggested that among transfusion recipients, these changes may be associated with increased complications, infections, and mortality. A study published in 2008 found that among cardiac surgery patients, transfusion of 
RBCs stored for more than 14 days was associated with increased in-hospital morbidity and mortality. However, rigorous evidence on the effect of prolonged storage on clinical outcomes in patients has been largely unavailable.

The Age of Red Blood Cells in Premature Infants trial, also known as ARIPI , was a double-blind, randomized controlled trial conducted by researchers from six Canadian tertiary neonatal intensive care units. The trial assessed the effect of RBC storage time on morbidity and mortality among premature, low-birth-weight infants. It compared outcomes of patients receiving fresh red blood cells, which had been stored for less than 7 days, with patients receiving standard-issue units, which had been stored for an average of 14.6 days. The researchers found no significant difference in 90-day morbidity or mortality between trial arms. The results were presented at the Boston AABB meeting and published in the Journal of the American Medical Association.

Dr. Dean Fergusson was the principal investigator of the trial and noted:
“The ARIPI trial demonstrates that current transfusion management and practice does not need to be changed for blood banks servicing neonatal intensive care units. Whether the results of ARIPI are generalizable to other populations requiring transfusions remains unknown.”

A further understanding of the clinical implications of prolonged red blood cell storage is critical to establishing effective transfusion policy. Fortunately, multiple randomized trials in adults are currently underway.

1.    Fergusson DA, Hebert P, Hogan DL, Lebel L, Rouvinez-Bouali N, Smyth JA, Sankaran K, Tinmouth A, Blajchman MA, Kovacs L, Lachance C, Lee S, Walker CR, Hutton B, Ducharme R, Balchin K, Ramsay T, Ford JC, Kakadekar A, Ramesh K, Shapiro S. Effect of Fresh Red Blood Cell Transfusions on Clinical Outcomes in Premature, Very Low-Birth-Weight Infants: The ARIPI Randomized Trial. JAMA 2012: 1-9.

2.    Lacroix J, Hebert P, Fergusson D, Tinmouth A, Blajchman MA, Callum J, Cook D, Marshall JC, McIntyre L, Turgeon AF. The Age of Blood Evaluation (ABLE) randomized controlled trial: study design. Transfus Med Rev 2011;25: 197-205

3.    Edgren G, Kamper-Jorgensen M, Eloranta S, Rostgaard K, Custer B, Ullum H, Murphy EL, Busch MP, Reilly M, Melbye M, Hjalgrim H, Nyren O. Duration of red blood cell storage and survival of transfused patients (CME). Transfusion 2010;50: 1185-95.

4.    Flegel WA. Fresh blood for transfusion: how old is too old for red blood cell units? Blood Transfus 2012;10: 247-51.

5.    Koch CG, Li L, Sessler DI, Figueroa P, Hoeltge GA, Mihaljevic T, Blackstone EH. Duration of red-cell storage and complications after cardiac surgery. N Engl J Med 2008;358: 1229-39.

6.    Wang D, Sun J, Solomon SB, Klein HG, Natanson C. Transfusion of older stored blood and risk of death: a meta-analysis. Transfusion 2012;52: 1184-95.

Date Posted: October 29, 2012
Source: Transfusion News