The “urgent development of transplant-specific anaemia guidelines” and a need for “rigorous patient blood management (PBM)” for those who receive kidney transplants—these are among the recommendations from authors of new research published in Frontiers in Nephrology on the prevalence of blood transfusion in UK transplant centres, and its association with transplant outcomes.
The authors, including first author Sevda Hassan (Imperial College London, London, UK), argue that PBM is a proven and World Health Organization (WHO)-approved approach to limiting “inappropriate” blood transfusions, which leads to both better outcomes and lower costs. They note that kidney transplant recipients represent a unique challenge in PBM, given their high rates of anaemia as well as factors exacerbating the condition, such as the frequent use of immunosuppressants to facilitate positive graft outcomes.
Despite this, they say, “guidance on post-transplant anaemia management frequently defaults to replicate protocols in the non-dialysis chronic kidney disease (CKD) population”. Citing a lack of evidence on the risks of transfusion in kidney recipients, they note a wide range in transfusion rates for this patient population of 18.1–74.6%.
The implementation of PBM to prevent inappropriate transfusions—which may lead transplant recipients to develop human leukocyte antigen (HLA) antibodies that could contribute to graft failure—demands data on “who is being transfused, why they are being transfused and the impact, if any, that transfusion has on outcomes”, the authors add.
With the collaboration of the UK National Health Service Blood and Transplant Service (NHSBT), the British Transplant Society (BTS) and the HLA matched Red Cell Working Group, the study took place across four UK centres. From a total of 720 kidney transplant patients, 221 (30.7%) received blood transfusion, 214 (29.7%) of whom received red blood cell transfusion. The remaining patients were not transfused.
Patient survival at 12 months post-transplant was found to be inferior in the transfused group at 93.5% (95% confidence interval [CI] 88.3–96.5) compared with 99.3% (95% CI 97.7–99.8) in the non-transfused group (p<0.0001). Patients who were transfused experienced a lower rate of graft survival of 89.0% (95% CI 83.7–92.6) than the 97.2% rate of non-transfused patients (95% CI 95.3–98.4; p<0.0001). Renal transplant function was also found inferior in the transplanted group.
The authors performed risk-adjusted Cox proportional hazard model analysis which showed that transfusion was associated with inferior one-year patient survival (hazard ratio [HR] 7.94 [2.08–30.27]; p=0.002), allograft survival (HR: 3.33 [1.65–6.71]; p=0.0008) and inferior allograft function.
“It is the first couple of weeks [after transplantation] where efforts to optimise anaemia management needs to be prioritised in the first instance,” the authors suggest in their discussion. They add that “adequate iron therapy in the pre-transplant setting is of the utmost importance” as a further recommendation, and say it is “imperative to investigate, where indicated, occult causes of blood loss and iron deficiency” as part of investigation of causes of potential anaemia prior to transplantation.
Hassan et al go on to say that “the need for blood transfusions will never be eradicated”, and that, though they did not study medium- and long-term consequences of transfusion in transplant patients, the area warrants more study. The data from their study also suggest that, in the UK, non-white ethnicity is a risk factor for transfusion, and given that non-white patients experience inferior allograft survival, “this again supports the call for research in this area”, they add.
“PBM applied to general surgical procedures has been shown to reduce the need for transfusions and improve patient outcomes by lowering morbidity and mortality,” they conclude, also stating that blood transfusions remain “common” despite association with inferior graft outcomes. Noting a “call to action” to implement PBM by the WHO, they identify a need for transplant-specific anaemia guidelines as well as further research on the connection between transfusion and transplant failure.
Corresponding author Michelle Willicombe (Imperial College London) noted that the work of the study was undertaken prior to the untimely passing of Sevda Hassan.
