BLOOD TRANSFUSION IN APLASTIC ANEMIA

Blood transfusion is the process of transferring blood components from one

person (donor) to another (recipient). Where this blood transfusion can be complete

blood or only blood components that are needed. Aplastic anemia is a disease that

occurs when the bone marrow stops producing blood cells, including red blood cells,

white blood cells, and platelets, which can cause anemia (NIH, 2012). Although aplastic

anemia is a rare disease, this disease cannot be underestimated because it is a serious

problem, the condition in patients with aplastic anemia will be very dangerous if it is

not treated properly. Blood cells that have an important role in the body fail to be

produced, thus requiring blood transfusion as a supportive treatment to improve the

patient's quality of life (Killick et al., 2016).

Indications

Red cell and platelet transfusions should be given to maintain a safe

haemoglobin level (>80 g/l) and platelet counts, platelet transfusion is the mainstay of

therapy in all patients with aplastic anemia who are severely deficient in blood cells

although this will depend on comorbidities and the physical state of the patient (German

Association of Physicians, 2009). The decision to transfuse red cell should be based on

anemia aplastic patients with clinical symptoms (signs of anemia and pancytopenia),

Hb value, taking into consideration the patient's age, quality of life, and comorbidities

such as cardiac, pulmonary or vascular disease (Carson, 2012).

Prophylactic platelet transfusion is recommended if the platelet count is <10 x

109 / l (or <20 x 109 / l at the time of fever (Kelsey et al, 2003) and patients with bleeding

sign (including petechial bleeding ) or history of major bleeding events (Mars et al.,

2009). Patients with a low platelet count of less than 10,000 per microliter of blood is
considered low enough to need a platelet transfusion. But each person reacts differently

to a low platelet count. Other source said that blood transfusion could be needed in

anemia aplastic patients with no symptoms of anemia and no high risk factors by

mantaining hemoglobin of 6 - 7 g/dL, evidence of cardiovascular, pulmonary or

cerebrovascular disease that may need to be transfused by mantaining hemoglobin of ≥

7 g/dL. The exact therapeutic concentration needs to be individualized for each patient

(NYS Council, 2012).

Contraindications

Routine prophylactic platelet transfusions are not recommended for stable

anemia aplastic patients that not on active treatment. If a patient is considered for a stem

cell transplant, it is important not to accept blood transfusions or blood products from

family members. This is because the transfuse may affect the success of the transplant

from the donor that will be carried out in the future (Ken Campbelll, 2010).

Blood Components

There are 2 types of blood transfusions that are often given in aplastic anemia,

transfusions of red blood cells and platelets (WHO, 2011),(Transfusion Medicine

Handbook, 2016),(Norfolk, 2013):

1. Red blood cells

Patients with aplastic anemia who need treatment will require a red blood cell

transfusion. Packed red cells are obtained from the separation or secretion of the plasma

in a closed or septic manner such that the hematocrit becomes 70-80%. The volume

depends on the blood bag used, around 150-300 ml. Store temperature 4° ± 2° C. Blood

storage time 24 hours with an open system. Packed cells are components consisting of

erythrocytes that have been concentrated by separating other components. To increase

the Hb level by 1g/dl, PRC 4ml/kgBW or 1 unit is needed to increase the hematocrit
levels by 3-5%. Administer for 2 to 4 hours at a rate of 1-2 mL/ minute, with known

ABO and Rh blood groups.

Aplastic anemia patients may also need to transfuse other types of blood

components. Because patients need multiple transfusions, they should always receive

as many blood products with removed white cells through leucodepletion because the

white cells can trigger the patient's immune system to produce antibodies.

2. Platelets

Platelet administration is often necessary in cases of bleeding caused by a

deficiency of platelets. Repeated administration of platelets can lead to the formation

of thrombocyte antibodies in patients. Platelet components have a shelf life of up to 3

days. Platelet Rich Plasma (platelet rich plasma) is made with how to separate plasma

from fresh blood. Storage of 34°C preferably 24 hours. Platelet Concentrate

(concentrated platelets), the volume is 50 ml with a storage temperature of 20° ± 2°C

useful for increasing the platelet count. The increase in post transfusion in adults

averaged 5,000-10,000/ul. Side effects include urticaria, chills, fever, and

alloimmunization of donor platelet antigen.

Procedures

Generally, no limit to the number of blood transfusions that can be performed,

but complications can sometimes arise with repeated transfusions (Mayo Clinic, 2020).

Prophylactic platelet transfusions should be given to stable anemia aplastic patients

who is receiving active treatment. A threshold (pre‐transfusion) platelet count of

10 × 10 9/l should be used. In patients judged to have additional risk factors for

bleeding, such as fever or sepsis, a higher prophylactic transfusion threshold of

20 × 10 9 /l is recommended. In patients judged to have additional risk factors for

20 × 10 9 /l is recommended (Killick, 2016).

Before performing a blood transfusion, both red blood cell and platelet

transfusions, the patient's blood will be tested to see if it matches the donor's blood,

which usually lasts for 1 hour. Then the donor blood will be filtered and irrigated to

move and deactivate some cells, its function is to reduce the risk of a bad immune

response to the blood. After that given Tylenol and Benadryl before transfusion to

prevent fever and allergic reactions, then the blood is ready to be transfused.

Meanwhile, platelet transfusions are given if the platelets are <20,000 / μ L which

increases the risk of bleeding (Athar et al, 2012),(Janice and McFarland, 1999).

The indications for fresh-frozen plasma in anemia aplastic patients are the same

as those in the general transfusion guidelines (German Association of Physicians,

2009).

Uses and Benefits

Blood transfusion is safe and is a common procedure in patients with aplastic

anemia. The purpose of blood transfusion is to improve the ability to carry oxygen,

restore the volume of fluid that is released, improve the function of blood clotting, and

improve the ability of phagocytosis and increase the number of proteins in the blood

(Komisi transfusi, 2015). Blood transfusions are performed to reduce the risk of

bleeding, reduce the risk of infection, and relieve symptoms of anemia and

pancytopenia in patient by providing blood cells that cannot be produced by bone

marrow (Pickard et al., 2018).

Side Effects/Reactions

A common problem in multi-transfused patients with aplastic anaemia,

compared with leukaemia patients, is that they may develop alloimmunisation to

(minor histocompatibility) antibodies (Kaminsky et al, 1990). The blood transfusion

process may quickly stabilize aplastic anemia patients with severe blood cell

deficiencies, but it is very rare for a patient to achieve a long-term recovery using this

form of treatment alone. The red blood cells that are transfused contain iron which can

build up in the patient's body and can damage vital organs such as the liver and hormone

(endocrine) production, if excess iron is not treated. Over time, the patient's body can

develop antibodies to the transfused blood cells, making them less effective at relieving

symptoms (Bakhshi, 2020).

Patients who become refractory to platelet transfusions should be screened for

HLA antibodies. Directed blood and platelet donations from family members are not

permitted and the recipient may become sensitised to minor histo compatibility antigens

from the potential bone marrow donor resulting in a high risk of graft rejection. In

exceptional circumstances, a family donor may provide the most compatible platelets

if a patient has developed multi-specific HLA antibodies and requires platelet surgently

(Marsh, 2009).

Conclusions

Transfusion of red blood cells and platelets is an important supportive treatment

for patients with aplastic anemia by taking into the indications, contraindications,

procedures, side effects or reactions that can occur, and target limits for therapy. Blood

screening is the first step before transfusions so that the patient's body can respond well

the blood from donors. Good communication and cooperation are needed by all parties

related to blood transfusion services.

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