今日の臨床サポート

血小板輸血

著者: 山本晃士 埼玉医科大学総合医療センター 輸血細胞医療部

監修: 木崎昌弘 埼玉医科大学総合医療センター

著者校正/監修レビュー済:2022/03/02
参考ガイドライン:
  1. 日本輸血・細胞治療学会:科学的根拠に基づいた血小板製剤の使用ガイドライン:2019年改訂版
患者向け説明資料

概要・推奨   

  1. 造血障害に起因した血小板減少症の出血予防には、日本のガイドラインが設定している輸血トリガー値:1~2万/μLが強く推奨される(推奨度1)
  1. 血小板減少症の治療や手術などの侵襲的処置時の止血障害の予防のためには、血小板数:5万/μLを基準にした血小板輸血が推奨される(推奨度2)
  1. 血小板輸血の禁忌は、TTP/HUSやHITとされるが、活動性出血や出血のリスクが高い処置では血小板輸血を躊躇すべきではない(推奨度3)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
山本晃士 : 特に申告事項無し[2022年]
監修:木崎昌弘 : 講演料(武田薬品工業,ヤンセンファーマ,小野薬品工業,ブリストル・マイヤーズスクイブ),研究費・助成金など(武田薬品工業),奨学(奨励)寄付など(協和キリン,旭化成ファーマ,第一三共,中外製薬,日本新薬,武田薬品工業)[2022年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

まとめ

まとめ(適応、禁忌、合併症とそのリスク)  
まとめ:
  1. 血小板を補充して血小板の量的、質的低下に基づく出血の予防や治療を行う。
  1. 造血機能低下や消費亢進による血小板減少症や手術等の侵襲的処置時に用いる。
  1. 特有の副作用(アレルギー等の急性反応や感染症などの遅発性合併症)に注意する。<図表>
  1. 輸血前後の血小板数を測定して、輸血の効果(CCI)を評価する。 >詳細情報  >詳細情報 
  1. 血小板抗体(抗HLA抗体や抗HPA抗体)を検索する。<図表>
  1. 血小板抗体陽性のときは、HLA適合血小板を利用するために、患者のHLA(class1、AおよびB)を同定する。
 
震盪条件下で保存されている濃厚血小板

出典

img1:  半田誠先生ご提供
 
 
 
適応:
  1. 血小板減少症:血液疾患等に伴う造血器障害、播種性血管内凝固症候群( DIC )による消費亢進や大量輸液・輸血による血液希釈。
  1. 血小板機能低下症: 血小板無力症 等の先天性疾患や抗血小板薬等による後天性障害
  1. 外科的適応:血小板減少症や血小板機能低下症の手術等の侵襲的処置。
 
造血障害に起因した血小板減少による皮下出血

血小板数:5,000/μL>

出典

img1:  半田誠先生ご提供
 
 
 
禁忌:
  1. 原則なし。ただし多発性の血小板血栓を本態とする 血栓性血小板減少性紫斑病 (TTP)や 溶血性尿毒症症候群 (HUS)、そして ヘパリン起因性血小板減少症 (HIT)では慎重投与が必要である。
 
合併症とそのリスク<図表>
  1. アレルギーや呼吸不全等の非溶血性急性副作用が時々みられる。<図表>
  1.  B型肝炎 などの感染症伝播はごくまれであるが、リスクはゼロではない。<図表>
 
鑑別疾患表
  1. アレルギー反応(蕁麻疹、アナフィラキシー)
  1. 重症の急性肺障害(TRALI)
  1. 輸血後GVHD
  1. HBV
  1. HCV
  1. HIV
準備のポイント  
  1. 血小板減少のレベル(血小板数)と出血症状を確認する。

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文献 

Richard M Kaufman, Benjamin Djulbegovic, Terry Gernsheimer, Steven Kleinman, Alan T Tinmouth, Kelley E Capocelli, Mark D Cipolle, Claudia S Cohn, Mark K Fung, Brenda J Grossman, Paul D Mintz, Barbara A O'Malley, Deborah A Sesok-Pizzini, Aryeh Shander, Gary E Stack, Kathryn E Webert, Robert Weinstein, Babu G Welch, Glenn J Whitman, Edward C Wong, Aaron A R Tobian, AABB
Platelet transfusion: a clinical practice guideline from the AABB.
Ann Intern Med. 2015 Feb 3;162(3):205-13. doi: 10.7326/M14-1589.
Abstract/Text BACKGROUND: The AABB (formerly, the American Association of Blood Banks) developed this guideline on appropriate use of platelet transfusion in adult patients.
METHODS: These guidelines are based on a systematic review of randomized, clinical trials and observational studies (1900 to September 2014) that reported clinical outcomes on patients receiving prophylactic or therapeutic platelet transfusions. An expert panel reviewed the data and developed recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.
RECOMMENDATION 1: The AABB recommends that platelets should be transfused prophylactically to reduce the risk for spontaneous bleeding in hospitalized adult patients with therapy-induced hypoproliferative thrombocytopenia. The AABB recommends transfusing hospitalized adult patients with a platelet count of 10 × 109 cells/L or less to reduce the risk for spontaneous bleeding. The AABB recommends transfusing up to a single apheresis unit or equivalent. Greater doses are not more effective, and lower doses equal to one half of a standard apheresis unit are equally effective. (Grade: strong recommendation; moderate-quality evidence).
RECOMMENDATION 2: The AABB suggests prophylactic platelet transfusion for patients having elective central venous catheter placement with a platelet count less than 20 × 109 cells/L. (Grade: weak recommendation; low-quality evidence).
RECOMMENDATION 3: The AABB suggests prophylactic platelet transfusion for patients having elective diagnostic lumbar puncture with a platelet count less than 50 × 109 cells/L. (Grade: weak recommendation; very-low-quality evidence).
RECOMMENDATION 4: The AABB suggests prophylactic platelet transfusion for patients having major elective nonneuraxial surgery with a platelet count less than 50 × 109 cells/L. (Grade: weak recommendation; very-low-quality evidence).
RECOMMENDATION 5: The AABB recommends against routine prophylactic platelet transfusion for patients who are nonthrombocytopenic and have cardiac surgery with cardiopulmonary bypass. The AABB suggests platelet transfusion for patients having bypass who exhibit perioperative bleeding with thrombocytopenia and/or evidence of platelet dysfunction. (Grade: weak recommendation; very-low-quality evidence).
RECOMMENDATION 6: The AABB cannot recommend for or against platelet transfusion for patients receiving antiplatelet therapy who have intracranial hemorrhage (traumatic or spontaneous). (Grade: uncertain recommendation; very-low-quality evidence).

PMID 25383671
Susan Nahirniak, Sherrill J Slichter, Susano Tanael, Paolo Rebulla, Katerina Pavenski, Ralph Vassallo, Mark Fung, Rene Duquesnoy, Chee-Loong Saw, Simon Stanworth, Alan Tinmouth, Heather Hume, Arjuna Ponnampalam, Catherine Moltzan, Brian Berry, Nadine Shehata, International Collaboration for Transfusion Medicine Guidelines
Guidance on platelet transfusion for patients with hypoproliferative thrombocytopenia.
Transfus Med Rev. 2015 Jan;29(1):3-13. doi: 10.1016/j.tmrv.2014.11.004. Epub 2014 Nov 27.
Abstract/Text Patients with hypoproliferative thrombocytopenia are at an increased risk for hemorrhage and alloimmunization to platelets. Updated guidance for optimizing platelet transfusion therapy is needed as data from recent pivotal trials have the potential to change practice. This guideline, developed by a large international panel using a systematic search strategy and standardized methods to develop recommendations, incorporates recent trials not available when previous guidelines were developed. We found that prophylactic platelet transfusion for platelet counts less than or equal to 10 × 10(9)/L is the optimal approach to decrease the risk of hemorrhage for patients requiring chemotherapy or undergoing allogeneic or autologous transplantation. A low dose of platelets (1.41 × 10(11)/m2) is hemostatically as effective as higher dose of platelets but requires more frequent platelet transfusions suggesting that low-dose platelets may be used in hospitalized patients. For outpatients, a median dose (2.4 × 10(11)/m2) may be more cost-effective to prevent clinic visits only to receive a transfusion. In terms of platelet products, whole blood-derived platelet concentrates can be used interchangeably with apheresis platelets, and ABO-compatible platelet should be given to improve platelet increments and decrease the rate of refractoriness to platelet transfusion. For RhD-negative female children or women of child-bearing potential who have received RhD-positive platelets, Rh immunoglobulin should probably be given to prevent immunization to the RhD antigen. Providing platelet support for the alloimmunized refractory patients with ABO-matched and HLA-selected or crossmatched products is of some benefit, yet the degree of benefit needs to be assessed in the era of leukoreduction.

Copyright © 2015 Elsevier Inc. All rights reserved.
PMID 25537844
Sherrill J Slichter, Richard M Kaufman, Susan F Assmann, Jeffrey McCullough, Darrell J Triulzi, Ronald G Strauss, Terry B Gernsheimer, Paul M Ness, Mark E Brecher, Cassandra D Josephson, Barbara A Konkle, Robert D Woodson, Thomas L Ortel, Christopher D Hillyer, Donna L Skerrett, Keith R McCrae, Steven R Sloan, Lynne Uhl, James N George, Victor M Aquino, Catherine S Manno, Janice G McFarland, John R Hess, Cindy Leissinger, Suzanne Granger
Dose of prophylactic platelet transfusions and prevention of hemorrhage.
N Engl J Med. 2010 Feb 18;362(7):600-13. doi: 10.1056/NEJMoa0904084.
Abstract/Text BACKGROUND: We conducted a trial of prophylactic platelet transfusions to evaluate the effect of platelet dose on bleeding in patients with hypoproliferative thrombocytopenia.
METHODS: We randomly assigned hospitalized patients undergoing hematopoietic stem-cell transplantation or chemotherapy for hematologic cancers or solid tumors to receive prophylactic platelet transfusions at a low dose, a medium dose, or a high dose (1.1x10(11), 2.2x10(11), or 4.4x10(11) platelets per square meter of body-surface area, respectively), when morning platelet counts were 10,000 per cubic millimeter or lower. Clinical signs of bleeding were assessed daily. The primary end point was bleeding of grade 2 or higher (as defined on the basis of World Health Organization criteria).
RESULTS: In the 1272 patients who received at least one platelet transfusion, the primary end point was observed in 71%, 69%, and 70% of the patients in the low-dose group, the medium-dose group, and the high-dose group, respectively (differences were not significant). The incidences of higher grades of bleeding, and other adverse events, were similar among the three groups. The median number of platelets transfused was significantly lower in the low-dose group (9.25x10(11)) than in the medium-dose group (11.25x10(11)) or the high-dose group (19.63x10(11)) (P=0.002 for low vs. medium, P<0.001 for high vs. low and high vs. medium), but the median number of platelet transfusions given was significantly higher in the low-dose group (five, vs. three in the medium-dose and three in the high-dose group; P<0.001 for low vs. medium and low vs. high). Bleeding occurred on 25% of the study days on which morning platelet counts were 5000 per cubic millimeter or lower, as compared with 17% of study days on which platelet counts were 6000 to 80,000 per cubic millimeter (P<0.001).
CONCLUSIONS: Low doses of platelets administered as a prophylactic transfusion led to a decreased number of platelets transfused per patient but an increased number of transfusions given. At doses between 1.1x10(11) and 4.4x10(11) platelets per square meter, the number of platelets in the prophylactic transfusion had no effect on the incidence of bleeding. (ClinicalTrials.gov number, NCT00128713.)

2010 Massachusetts Medical Society
PMID 20164484
Lise J Estcourt, S J Stanworth, M F Murphy
Platelet transfusions for patients with haematological malignancies: who needs them?
Br J Haematol. 2011 Aug;154(4):425-40. doi: 10.1111/j.1365-2141.2010.08483.x. Epub 2011 May 25.
Abstract/Text The goal of platelet transfusions is to prevent severe and life-threatening bleeding in patients with thrombocytopenia. This aim needs to be balanced against the risks associated with platelet transfusions as well as the challenge of maintaining an adequate supply. This review summarizes the recent evidence regarding the clinical use of platelet transfusions in haematology patients, concentrating on the topics that still continue to provoke debate. These include the optimal dose for platelet transfusions and the relative safety of a 'therapeutic only' platelet transfusion strategy compared to the use of prophylactic platelet transfusions. The type of platelet product has been the subject of two recent systematic reviews. The results of these reviews will be discussed as well as their implications for current practice.

Published with the permission of the Controller of HMSO and the Queen's Printer for Scotland.
PMID 21615375
Ambuj Kumar, Rahul Mhaskar, Brenda J Grossman, Richard M Kaufman, Aaron A R Tobian, Steven Kleinman, Terry Gernsheimer, Alan T Tinmouth, Benjamin Djulbegovic, AABB Platelet Transfusion Guidelines Panel
Platelet transfusion: a systematic review of the clinical evidence.
Transfusion. 2015 May;55(5):1116-27; quiz 1115. doi: 10.1111/trf.12943. Epub 2014 Nov 12.
Abstract/Text BACKGROUND: Platelet (PLT) transfusion is indicated either prophylactically or therapeutically to reduce the risk of bleeding or to control active bleeding. Significant uncertainty exists regarding the appropriate use of PLT transfusion and the optimal threshold for transfusion in various settings. We formulated 12 key questions to assess the role of PLT transfusion.
STUDY DESIGN AND METHODS: We performed a systematic review (SR) of randomized controlled trials (RCTs) and observational studies. A comprehensive search of PubMed, Web of Science, and Cochrane registry of controlled trials was performed. Methodologic quality of included studies was assessed and a meta-analysis was performed if more than two studies with similar designs were identified for a specific question.
RESULTS: Seventeen RCTs and 55 observational studies were included in the final SR. Results from RCTs showed a beneficial effect of prophylactic compared with therapeutic transfusion for the prevention of significant bleeding in patients with hematologic disorders undergoing chemotherapy or stem cell transplantation. We found no difference in significant bleeding events related to the PLT count threshold for transfusion or the dose of PLTs transfused. Overall methodologic quality of RCTs was moderate. Results from observational studies showed no evidence that PLT transfusion prevented significant bleeding in patients undergoing central venous catheter insertions, lumbar puncture, or other surgical procedures. The methodologic quality of observational studies was very low.
CONCLUSION: We provide a comprehensive assessment of evidence on the use of PLT transfusions in a variety of clinical settings. Our report summarizes current knowledge and identifies gaps to be addressed in future research.

© 2014 AABB.
PMID 25387589
P Rebulla, G Finazzi, F Marangoni, G Avvisati, L Gugliotta, G Tognoni, T Barbui, F Mandelli, G Sirchia
The threshold for prophylactic platelet transfusions in adults with acute myeloid leukemia. Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto.
N Engl J Med. 1997 Dec 25;337(26):1870-5. doi: 10.1056/NEJM199712253372602.
Abstract/Text BACKGROUND: Prophylactic platelet transfusions are usually administered to patients receiving myelotoxic chemotherapy when their platelet count falls below 20,000 per cubic millimeter. Some observations suggest that lower platelet counts can be appropriate in patients in stable condition, but the safety of lower thresholds is uncertain.
METHODS: We evaluated 255 adolescents and adults (age, 16 to 70 years) with newly diagnosed acute myeloid leukemia (but not acute promyelocytic leukemia), who were treated in 21 centers. One hundred thirty-five patients were randomly assigned to receive a transfusion when their platelet count fell below 10,000 per cubic millimeter (or 10,000 to 20,000 per cubic millimeter in those with a temperature above 38 degrees C, with active bleeding, or a need for invasive procedures), and 120 patients were assigned to receive a transfusion when their platelet count was less than 20,000 per cubic millimeter.
RESULTS: Patients in the group with a threshold of 10,000 platelets per cubic millimeter received 21.5 percent fewer platelet transfusions than the patients in the group with a threshold of 20,000 platelets per cubic millimeter (P=0.001). The numbers of red-cell units transfused were not significantly different between groups. Major bleeding (defined as any bleeding more than petechiae or mucosal or retinal bleeding) occurred in 21.5 and 20 percent of patients, respectively (P=0.41), and on 3.1 and 2.0 percent of the days of hospitalization. One episode of fatal cerebral hemorrhage occurred in the group with a threshold of 10,000 platelets per cubic millimeter; none occurred in the other group (P= 0.95). Actuarial estimates of survival during induction chemotherapy, actuarial estimates of the absence of major bleeding, and the length of hospital stay were not significantly different in the two groups.
CONCLUSIONS: The risk of major bleeding during induction chemotherapy in adolescents and adults with acute myeloid leukemia (except acute promyelocytic leukemia, which we did not study) was similar with platelet-transfusion thresholds of 20,000 per cubic millimeter and 10,000 per cubic millimeter (or 10,000 to 20,000 per cubic millimeter when body temperature exceeded 38 degrees C, there was active bleeding, or invasive procedures were needed). Use of the lower threshold reduced platelet use by 21.5 percent.

PMID 9407153
C A Schiffer, K C Anderson, C L Bennett, S Bernstein, L S Elting, M Goldsmith, M Goldstein, H Hume, J J McCullough, R E McIntyre, B L Powell, J M Rainey, S D Rowley, P Rebulla, M B Troner, A H Wagnon, American Society of Clinical Oncology
Platelet transfusion for patients with cancer: clinical practice guidelines of the American Society of Clinical Oncology.
J Clin Oncol. 2001 Mar 1;19(5):1519-38.
Abstract/Text OBJECTIVE: To determine the most effective, evidence-based approach to the use of platelet transfusions in patients with cancer.
OUTCOMES: Outcomes of interest included prevention of morbidity and mortality from hemorrhage, effects on survival, quality of life, toxicity reduction, and cost-effectiveness.
EVIDENCE: A complete MedLine search was performed of the past 20 years of the medical literature. Keywords included platelet transfusion, alloimmunization, hemorrhage, threshold and thrombocytopenia. The search was broadened by articles from the bibliographies of selected articles.
VALUES: Levels of evidence and guideline grades were rated by a standard process. More weight was given to studies that tested a hypothesis directly related to one of the primary outcomes in a randomized design. BENEFITS/HARMS/COST: The possible consequences of different approaches to the use of platelet transfusion were considered in evaluating a preference for one or another technique producing similar outcomes. Cost alone was not a determining factor.
RECOMMENDATIONS: Appendix A summarizes the recommendations concerning the choice of particular platelet preparations, the use of prophylactic platelet transfusions, indications for transfusion in selected clinical situations, and the diagnosis, prevention, and management of refractoriness to platelet transfusion.
VALIDATION: Five outside reviewers, the ASCO Health Services Research Committee, and the ASCO Board reviewed this document.
SPONSOR: American Society of Clinical Oncology

PMID 11230498
Jecko Thachil
The myths about platelet transfusions in immune-mediated thrombocytopenias.
Br J Haematol. 2010 Aug;150(4):494-5. doi: 10.1111/j.1365-2141.2010.08231.x. Epub 2010 May 9.
Abstract/Text
PMID 20507308
Harvey G Klein, Donat R Spahn, Jeffrey L Carson
Red blood cell transfusion in clinical practice.
Lancet. 2007 Aug 4;370(9585):415-26. doi: 10.1016/S0140-6736(07)61197-0.
Abstract/Text Every year, about 75 million units of blood are collected worldwide. Red blood cell (RBC) transfusion is one of the few treatments that adequately restore tissue oxygenation when oxygen demand exceeds supply. Although the respiratory function of blood has been studied intensively, the trigger for RBC transfusion remains controversial, and doctors rely primarily on clinical experience. Laboratory assays that indicate failing tissue oxygenation would be ideal to guide the need for transfusion, but none has proved easy, reproducible, and sensitive to regional tissue hypoxia. The clinical importance of the RBCs storage lesion (ie, the time-dependent metabolic, biochemical, and molecular changes that stored blood cells undergo) is poorly understood. RBCs can be filtered, washed, frozen, or irradiated for specific indications. Donor screening and testing have dramatically reduced infectious risks in the developed world, but infection remains a major hazard in developing countries, where 13 million units of blood are not tested for HIV or hepatitis viruses. Pathogen inactivation techniques are in clinical trials for RBCs, but none is available for use. Despite serious immunological and non-immunological complications, RBC transfusion holds a therapeutic index that exceeds that of many common medications.

PMID 17679019
輸血情報 1310-136、日本赤十字社、輸血用血液製剤との関連性が高いと考えられた感染症症例-2012-(日本赤十字社医薬品情報[医療関係者向け情報サイト]/医薬品情報).
輸血情報 1310-137、日本赤十字社、赤十字血液センターに報告された非溶血性輸血副作用-2012-(日本赤十字社医薬品情報[医療関係者向け情報サイト]/医薬品情報).
Hiroshi Azuma, Junichi Hirayama, Mitsuaki Akino, Reiko Miura, Yoshio Kiyama, Kiyotoshi Imai, Masaharu Kasai, Kazuki Koizumi, Yasutaka Kakinoki, Yusuke Makiguchi, Koji Kubo, Yoshiko Atsuta, Mitsuhiro Fujihara, Chihiro Homma, Sadamitsu Yamamoto, Toshiaki Kato, Hisami Ikeda
Reduction in adverse reactions to platelets by the removal of plasma supernatant and resuspension in a new additive solution (M-sol).
Transfusion. 2009 Feb;49(2):214-8. doi: 10.1111/j.1537-2995.2008.01918.x. Epub 2008 Sep 16.
Abstract/Text BACKGROUND: Leukodepletion reduces but does not eliminate adverse reactions to platelet concentrate (PC). As an alternative strategy, plasma reduction or washing of platelets should be considered. However, the efficacy of this strategy is still unclear.
STUDY DESIGN AND METHODS: A total of 12 patients who experienced adverse reactions at a 29 to 100 percent reaction rate for plasma-PC were enrolled. The reactions were allergic reactions and nonhemolytic transfusion reactions, such as chills. Plasma-removed PC (W/R-PC), which was suspended in a recently developed additive solution (M-sol) containing less than 20 mL plasma, was prepared. W/R-PCs in M-sol were then transfused into patients after an overnight storage period; the occurrence of adverse reactions was monitored and 1- and 24-hour corrected count increment (CCI) values were evaluated.
RESULTS: Although plasma-PC caused reaction in 12 patients, W/R-PC prevented reactions in 11 of 12 patients, with 1 patient having one minor allergic reaction of 15 transfusions. There was a significant difference in the incidence of reaction (p < 0.0001, Fisher's exact test). On a per-transfusion basis, the reaction rate for W/R-PC (1/156, 0.64%; 95% confidence interval [CI], 0.02%-3.5%) was reduced significantly compared to that for plasma-PC (117/276, 42%; 95% CI, 36%-48%; p < 0.0001). W/R-PC gave findings of satisfactory CCI at 1 hour (22,400 +/- 8,000/microL) and 24 hours (15,400 +/- 8,000/microL). No clinically evident bleeding episodes were recorded.
CONCLUSIONS: W/R-PC suspended in M-sol in the presence of less than 20 mL plasma can be transfused safely and eliminate a wide range of adverse reactions to plasma-PC.

PMID 18798806
Aaron A R Tobian, William J Savage, Daniel J Tisch, Sandra Thoman, Karen E King, Paul M Ness
Prevention of allergic transfusion reactions to platelets and red blood cells through plasma reduction.
Transfusion. 2011 Aug;51(8):1676-83. doi: 10.1111/j.1537-2995.2010.03008.x. Epub 2011 Jan 7.
Abstract/Text BACKGROUND: The incidence of allergic transfusion reactions (ATRs) ranges from 1% to 3% of all transfusions, and they are difficult to prevent. This study evaluated whether removing plasma from apheresis platelets (APs) or red blood cells (RBCs) by concentrating or washing transfusion products can decrease the incidence of ATRs.
STUDY DESIGN AND METHODS: A retrospective cohort study of 179 individuals who received unmanipulated and subsequently concentrated and/or washed APs was conducted. Poisson regression with generalized estimating equations was used to estimate the incident rate ratios and 95% confidence intervals (CIs) of ATRs.
RESULTS: The incidence of ATRs to unmanipulated APs was 5.5% (306 ATRs/5575 AP units). The incidence decreased to 1.7% (135 ATRs/4327 AP units) when individuals received concentrated APs (73% reduction; 95% CI, 65%-79%) and 0.5% (21 ATRs/4082 AP units) when individuals received washed APs (95% reduction; 95% CI, 91%-97%). Of the 39 individuals who received unmanipulated RBCs and subsequently washed RBCs, the incidence of ATRs decreased from 2.7% (33 ATRs/1236 RBC units) to 0.3% (2 ATRs/733 RBC units; 89.4% reduction; 95% CI, 55.5%-97.5%). The median number of AP transfusions to first ATR was six (interquartile range [IQR], 2-19) for unmanipulated APs and increased to 13 (IQR, 4-32) for concentrated APs and 40 (IQR, 29-73.5) for washed APs.
CONCLUSIONS: Concentrating APs and washing APs and RBCs substantially reduces ATRs, suggesting that the plasma component of APs and RBCs has an essential role in the etiology of ATRs.

© 2010 American Association of Blood Banks.
PMID 21214585
K Ogasawara, J Ueki, M Takenaka, K Furihata
Study on the expression of ABH antigens on platelets.
Blood. 1993 Aug 1;82(3):993-9.
Abstract/Text We recently examined a case of refractoriness to HLA-matched, ABO-incompatible platelet transfusions. The transfused platelets that were rapidly cleared from the circulation of the recipient expressed an amount of B antigen more than 20 times that expressed by the blood group B platelets that were successfully transfused to the recipient. These observations led us to conduct enzyme-linked immunosorbent assay (ELISA) and immunoblotting studies of the amount of blood A and B antigens expressed on the surface of platelets from randomly selected donors. The donors were clearly classified, according to the amount of A or B antigen expressed on their platelets, into two phenotypes, the high-expression and low-expression phenotypes. By ELISA, 7% of the examined donors were determined as belonging to the high-expression phenotype of either A or B antigen. The high-expression phenotype was independent of secretor phenotype. In transferase activity assay, a donor with high expression of B had increased B transferase activity in her serum, which suggested that the high-expression phenotype might be under the control of the glycosyltransferase gene. Family studies showed a dominant inheritance pattern of the high-expression phenotype. This report provides evidence that the expression of ABH antigens on platelets is genetically determined and that the ABO group should be given some attention in platelet transfusions.

PMID 8338959
J M Heal, J M Rowe, N Blumberg
ABO and platelet transfusion revisited.
Ann Hematol. 1993 Jun;66(6):309-14.
Abstract/Text Historically, ABO compatibility between donor and recipient has been considered of minor importance for platelet transfusion. However, in a recent randomized trial we showed that provision of only ABO-identical platelets was associated with a significantly higher corrected count increment (CCI) in the early transfusions and with a twofold reduction in refractoriness, as compared with platelets given unmatched for ABO. In older studies this phenomenon was not observed. We wondered whether in these previous studies the use of the conventional term "ABO compatible", whereby ABO-identical platelet transfusions are grouped with those that are merely ABO compatible, might have obscured the advantages of the ABO-identical platelets. In this paper the CCI from our original study are compared with what would have been found had the conventional terminology of "ABO compatible" and "ABO incompatible" been used. In our original study the mean CCI in patients receiving only ABO-identical platelets was 64% higher than that achieved with ABO-unmatched products. However, when the transfusions were reanalyzed according to conventional terminology of ABO "compatible" and "incompatible," the actual benefits of ABO-identical platelets were no longer detected. Thus, had we used the conventional terminology in the original study we would have come to completely different conclusions about the importance of ABO in platelet transfusion. We hypothesize that transfusion of ABO-incompatible plasma leads to the formation of immune complexes that can destroy compatible platelets by indirect mechanisms. This model predicts that the success of a transfusion could be affected by previous incompatible transfusions. When transfusions were classified as to whether they were first, second, or third unmatched transfusion, increasing numbers of transfusions of ABO-incompatible plasma were associated with progressively poorer mean increments. The same was true for platelet ABO-incompatible transfusions. In contrast, increasing numbers of ABO-identical transfusions were not associated with poorer increments. The failure to appreciate that (a) transfusions containing ABO-incompatible plasma yield poor increments and (b) the effects of ABO-nonidentical transfusions are cumulative, and therefore affect the success of subsequent identical transfusions, may have led in the past to the incorrect conclusion that ABO matching was of minor importance in repetitively transfused patients.

PMID 8318561
Sherrill J Slichter
Evidence-based platelet transfusion guidelines.
Hematology Am Soc Hematol Educ Program. 2007;:172-8. doi: 10.1182/asheducation-2007.1.172.
Abstract/Text Transfused platelets (plts) are either pooled random-donor platelet (plt) concentrates or single-donor apheresis plts. When stored for 5 days, all of these products are equally efficacious. A 10,000/microL prophylactic plt transfusion trigger has been documented to be both hemostatically efficacious and cost effective in reducing plt transfusion requirements. The optimal plt dose/transfusion is being evaluated in an ongoing clinical trial. Therapeutic plt transfusions to control or prevent bleeding with trauma or surgical procedures require higher transfusion triggers of 100,000/microL for neurosurgical procedures and between 50,000/microL and 100,000/microL for other invasive procedures or trauma. Leukoreduction has been documented to reduce plt alloimmunization rates, cytomegalovirus (CMV) transmission by transfusion, and febrile transfusion reactions. Whether it reduces immunomodulatory effects of transfusion (i.e., decreases infection rates and cancer recurrence) is still controversial, as is universal leukoreduction. Poor responses to plt transfusions are often multifactorial. For alloimmune plt refractoriness, HLA matching, cross-matching, and identification of the specificity of the patient's antibodies with avoidance of mismatched donor antigens are all equally effective in identifying compatible plts for transfusion. Other causes of poor plt responses are splenomegaly, ABO mismatching, females with 2 or more pregnancies and males, use of heparin or amphotericin, bleeding, fever, graft-vs-host disease (GVHD), and vaso-occlusive disease (VOD).

PMID 18024626
British Committee for Standards in Haematology, Blood Transfusion Task Force
Guidelines for the use of platelet transfusions.
Br J Haematol. 2003 Jul;122(1):10-23.
Abstract/Text
PMID 12823341

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