Observational Study of Transfusion Support and Hemorrhagic Tendencies in Newly Diagnosed Patients of AML Undergoing Chemotherapy

Research Article

J Blood Disord. 2014;1(3): 5.

Observational Study of Transfusion Support and Hemorrhagic Tendencies in Newly Diagnosed Patients of AML Undergoing Chemotherapy

Chaurasia R1*, Elhence P2, Nityanand S3, Verma A2 and Zaman S

1Department of Transfusion Medicine, All India Institute of Medical Sciences, India

2Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, India

3Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, India

*Corresponding author: Rahul Chaurasia, Department Of Transfusion Medicine, All India Institute of Medical Sciences, New Delhi, India.

Received: October 08, 2014; Accepted: November 06, 2014; Published: November 07, 2014

Abstract

Background: Transfusion support is an important and integral aspect for management of as substantial amount of blood may be required per patient during course of chemotherapy. We undertook this study to evaluate the quantitative aspect of blood component support in newly diagnosed AML patients undergoing chemotherapy. We also documented bleeding outcomes during the course of treatment.

Methods: Newly diagnosed 19 patients who opted for chemotherapy were included in the study. Quantitative transfusion details throughout the chemotherapy were recorded. Presence of fever, bleeding, infection/sepsis and splenomegaly, use of medications such as chemotherapeutic agents, AMB, G-CSF and antifibrinolytics before every transfusion were also recorded.

Results: Mean requirement of Leucopoor Red Blood Cells (LPRBC), Random Donor Platelets (RDP) and Fresh Frozen Plasma (FFP) was 14, 81.6 and 10 units respectively. Transfusion needs were more during induction as compared to consolidation phase. Bleeding was noted on 19.7 % patient days. Modified WHO grade 1 bleeding was observed on 115 days (8.8%) followed by grade 2 (6.6%) and grade 3 (4.2%). the most common site for bleeding was gastrointestinal tract (28.5%) followed by oropharynx (19.1%) patient days. No bleeding related mortality was noted.

Conclusion: The study provided insights into the complex issues of transfusion requirement of AML patients. We emphasize individualizing transfusion management of these patients as clinical factors are the major determinants of transfusion requirements. We also recommend that bleeding grades should be used as an outcome measure when determining the efficacy of platelet transfusions.

Keywords: Acute myeloid leukemia; Transfusion; Red blood cells; Platelets; Chemotherapy; Bleeding

Introduction

Over the past three decades, chemotherapy regimens and supportive care have been extensively improved and major advances have been made in the diagnosis and management of acute myeloid leukaemia (AML) [1]. Patients with acute leukemia usually present with features of bone marrow failure and symptoms and signs related to anemia, thrombocytopenia and neutropenia. Hemostatic abnormalities are common occurrences in these patients in as much as 50% of patients have platelet counts < 50x109/L [2]. Clinically thrombocytopenia in these patients manifests as easy bruising, petechie, epistaxis, gingival bleeding, conjunctival hemorrhages, and prolonged bleeding from skin injuries. Recent studies have elucidated coexistent thrombocytopathies in form of defective platelet aggregation, inadequate 5-hydroxytryptamine release and poor granulations [3]. In addition occasional patients may also experience rapid destruction of red cells due to an unknown mechanism (milieu hemolysis) [4]. During the course of treatment, chemotherapy causes myelosupression which further deranges the already disturbed haemostatic parameters. Laboratory studies almost constantly show marked decreases in red cells and platelets. Therefore, Red cell transfusions are given to maintain hemoglobin level greater than 8.0 g/ dl. Platelet transfusions used for hemorrhagic manifestations related to thrombocytopenia and prophylactically if necessary to maintain the platelet count above 10 x109/L [5]. Clotting abnormalities are managed by transfusion of fresh frozen plasma and cryoprecipitate. Hence, Transfusion support is integral to patient care and substantial amount of blood may be required per patient. However, there is little information about the transfusion requirements of these patients. We undertook this study to evaluate the quantitative aspect of blood component support in newly diagnosed AML patients undergoing chemotherapy. We also documented bleeding outcomes during the course of treatment.

Material and Methods

The study was carried at the Department of Transfusion Medicine in conjunction with Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, over a period of 18 months. The study was approved by Institutional ethical committee. A total of 175 new patients were diagnosed as AML during the study period, 54 opted for chemotherapy. Only 19 of these patients were enrolled in study. Patients were excluded from the study if they had acute promyelocytic leukemia, secondary AML, if they had received a blood transfusion before the diagnosis of AML, or if they declined to participate.

Patient details

Patient particulars noted included registration number, age, gender, height, weight, ABO and Rh blood group, diagnosis including FAB subtype and phase of chemotherapy. Clinical details such as presence of fever, infection/sepsis, splenomegaly and medications including chemotherapeutic agents (AMB, G-CSF, tranexamic acid) were also noted. Complete blood counts (CBC) were done every morning.

Treatment regimen

Standard treatment regimen during induction included Daunorubicin (60-90mg /m2) for 3 days and cytarabine (100- 200mg/m2) for 7 days. High dose cytarabine (1.5-3g/m2) was used for consolidation which was given every 12 hourly for day 1, 3 and 5. All patients who received treatment were followed up till complete remission, relapse, and resistance to chemotherapy or death whichever was earlier.

Transfusion support

Transfusion support given to patients was in form of Leuco Poor Red Blood Cells (LPRBC), Random Donor Platelets (RDP) prepared from whole blood (by Buffy-coat method) or Single Donor Platelets (SDP) and Fresh Frozen Plasma (FFP). RBC transfusions were given for Hb levels ≤8 g/dl or for symptomatic anemia. RDP/SDPs were transfused therapeutically in the presence of thrombocytopenic bleed and prophylactically when platelet count was ≤10x109/L or 10-20x109/L in the presence of risk factors such as fever, chemotherapy etc. Transfusion details recorded included component being administered, indication, trigger and number/dose of components transfused. Post transfusion samples were collected for determination of Hb and platelet counts. For monitoring efficacy of platelet transfusion, the post transfusion platelet counts were done both at 1 and 24 hours based on which Corrected Count Increment (CCI) was calculated.

Bleeding data

Patients were assessed daily for bleeding events by patient interview and physical examination. Results were reported using a modified WHO scale for bleeding [6]. Grade 0: no bleeding. Grade 1: Mild petechiae, ecchymosis and epistaxis/oral bleeding or occult blood loss. Grade 2: Moderate bleeds not requiring RBC transfusion e.g., large petechiae, ecchymosis, epistaxis, vaginal bleeding, mild hematemesis, melena, mild hematuria. Grade 3: Hemorrhage resulting in rapid decrease of HCT, necessitating RBC transfusions or failure to obtain a post transfusion increment. Grade 4: Hemorrhage resulting in severe hemodynamic compromise or bleeding into a vital organ (e.g. intracranial hemorrhage).

Statistical analysis and data management was done using SPSS statistical computer software (version 13.0, USA). Comparison between two groups were made using χ2 test for proportions. A 2-sided p value < 0.05 was considered significant.

Results

All study patients were followed for 32 chemotherapy cycles which included 19 inductions, 3 reinductions and 10 consolidation chemotherapy. The patient details are summarized in the Table 1. Mean duration of stay per chemotherapy cycle was 23.7(range 3-53) days while for entire treatment the mean duration of hospitalization was 68.5 (range 22-146) days.