Platelet Transfusion and Hemorrhage
Recently, two prospective randomized multicenter studies on hypoproliferative thrombocytopenia compared prophylactic transfusion of platelet concentrates below a threshold of 10 000/μL with therapeutic platelet transfusions only, administered at onset of hemorrhages other than mucocutaneous bleeding (1, 2). In the patient group with only therapeutic platelet transfusion, a significant increase in the incidence of grade 2, 3 or 4 (World Health Organization [WHO] bleeding scale) hemorrhages was observed. This applied to both patients with acute myeloid leukemia (AML) and patients after autologous stem cell transplantation. However, since the most severe form of hemorrhage—intracerebral hemorrhage—occurred only in AML patients, Wandt et al. (1) regarded the available evidence as being sufficient to adopt a therapeutic-only platelet transfusion strategy in adult, clinically stable patients after autologous stem cell transplantation.
However, this strategy requires monitoring at close intervals for signs of hemorrhage which can be realized during clinical studies, but not in a standard hospital setting. In addition, the immediate availability of platelet concentrates in the event of hemorrhage cannot be guaranteed at all times, even in tertiary care hospitals. Moreover, platelet concentrates with reduced platelet content and pathogen-inactivated platelet concentrates are commercially available in German-speaking countries. Prospective studies evaluating these types of platelet concentrates observed sporadic cases of intracranial hemorrhage even when platelet transfusions are applied prophylactically. To pursue a therapeutic-only platelet transfusion strategy using these types of platelet concentrates would expose patients to unpredictable risks.
In the best interest of the safety of patients suffering from hypoproliferative thrombocytopenia, we firmly reject the position of Wandt et al. (3) and agree with Professor Slichter from Seattle who wrote in a 2013 editorial of the New England Journal of Medicine (4), ‘In my opinion, the reduction in the use of platelet transfusions does not justify subjecting patients to the increased bleeding risks associated with a therapeutic-only platelet-transfusion strategy in any category of patients with hypoproliferative thrombocytopenia’.
Prof. Dr. med. Robert Zimmermann
PD Dr. med. Jürgen Zingsem
Prof. Dr. med. Reinhold Eckstein
und Hämostaseologische Abteilung
|1.||Wandt H, Schaefer-Eckart K, Wendelin K, et al.: Therapeutic platelet transfusion versus routine prophylactic transfusion in patients with haematological malignancies: an open-label, multicentre, randomised study. Lancet 2012; 380: 1309–16 CrossRef|
|2.||Stanworth SJ, Estcourt LJ, Powter G, et al.: A no-prophylaxis platelet-transfusion strategy for hematologic cancers. N Engl J Med 2013; 368: 1771–80 CrossRef MEDLINE|
|3.||Wandt H, Schäfer-Eckart K, Greinacher A: Platelet transfusion in hematology, oncology and surgery. Dtsch Arztebl Int 2014; 111: 809–15 VOLLTEXT|
|4.||Slichter SJ: Eliminate prophylactic platelet transfusions? N Engl J Med 2013; 368: 1837–8 CrossRef MEDLINE|