Both letters highlight the fact that the risk for hemorrhage varies between patients with thrombocytopenia. However, even doubling the standard dose of platelets in a prophylactic transfusion strategy cannot prevent clinically relevant hemorrhages, as it has been shown recently in a large study with more than 1000 patients (1). The same study also confirmed that the risk for hemorrhage varies widely between different patient populations. This risk was particularly low in patients after autologous stem cell transplantation. Today’s quality guidelines already provide different recommendations for each type of patients according to their risk for hemorrhage. The aim for the future is to further improve our ability to more clearly define risk groups (for example, patients with acute leukemia during induction chemotherapy) and identify low-risk patients (for example, patients after autologous stem cell transplantation) so that we can establish specific platelet transfusion regimes. The small population of patients with promyelocytic leukemia is, for example, at a very high risk for hemorrhage prior to achieving remission and at that time requires a particularly intensive treatment with platelet transfusions in combination with coagulation-modifying agents. We would like to thank J. Mezger for pointing this out in his letter. Likewise, the platelet counts of patients with prolonged episodes of hypoproliferative thrombocytopenia after intensive chemotherapy should be checked at least once or twice daily, as it was required in the prospective studies. However, contrary to the statement in R. Zimmermann’s letter, these studies did not require “monitoring at close intervals”. Hospitals where this minimum standard is not ensured and where adequate platelet transfusions cannot be provided within 4 hours after diagnosis of a hemorrhage (this was the timeframe required in those studies, not “immediate” transfusion) should not treat leukemia patients or perform hematopoietic stem cell transplantations at all. This applies regardless of the transfusion strategy used as it would involve unpredictable risks, not only with regard to hemorrhage.
Applying a therapeutic transfusion strategy to treat patients after autologous hematopoietic stem cell transplantation does not increase the risk for severe hemorrhage and reduces platelet transfusions by one third—this is confirmed by published data and recent experiences with several hundred patients. The likelihood of minor hemorrhage is slightly higher for the therapeutic transfusion strategy as it implies that platelet transfusion are only started once the patient has already developed a minor bleeding.
Transfusion specialists and experienced hematologists agree with this differentiated approach (2, 3). Platelet transfusion are not only beneficial, but allogenic, biological treatments that should only be administered after careful benefit-risk evaluation (4).
Further analysis of the available data (5) and additional clinical studies are needed to establish a differentiated platelet transfusion therapy that can be used in the future to improve the lives of our patients.
Prof. Dr. med. Hannes Wandt
Dr. med. Kerstin Schäfer-Eckart
Medizinische Klink 5
Hämatologie und Onkologie
Paracelsus Medizinische Privatuniversität Nürnberg
Prof. Dr. med. Andreas Greinacher
Institut für Immunologie und Transfusionsmedizin
Conflict of interest statement
The authors of all contributions declare that no conflict of interest exists.
|1.||Slichter SJ, Kaufman RM, Assmann SF, et al.: Dose of prophylactic platelet transfusions and prevention of hemorrhage. N Engl J Med 2010; 362: 600–13 CrossRef MEDLINE PubMed Central|
|2.||Schiffer CA: Prophylactic platelet transfusion is frequently not necessary. Nat Rev Clin Oncol 2013; 10: 431–2 CrossRef MEDLINE|
|3.||Schiffer CA: They took a mulligan and mostly got it right . . . the issue of prophylactic platelet transfusion for patients receiving autologous stem cell transplantation. Transfusion 2014; 54: 2372–4 CrossRef MEDLINE|
|4.||Blumberg N, Heal JM, Phillips GL, Phipps RP: Platelets – to transfuse or not to transfuse. Lancet 2012; 380: 1287–89 CrossRef|
|5.||Wandt H, Schäfer-Eckart K, Greinacher A: Platelet transfusion in hematology, oncology and surgery. Dtsch Arztebl Int 2014; 111: 809–15 VOLLTEXT|