Transfusion practices in cirrhotic patients at a tertiary liver care center from Northern India

Kakkar, Brinda; Maiwall, Rakhi; Bajpai, Meenu

doi:10.1016/j.htct.2020.05.010

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Hematology, Transfusion and Cell Therapy

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Sumário

Original article • Hematol., Transfus. Cell Ther. 43 (03) • Jul-Sep 2021 • https://doi.org/10.1016/j.htct.2020.05.010 copy

Transfusion practices in cirrhotic patients at a tertiary liver care center from Northern India

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

Transfusion in cirrhotic patients remains a challenge due to the absence of evidence-based guidelines. Our study aimed to determine the indication of transfusion and the associated transfusion thresholds in cirrhotic patients.

Methods:

This retrospective observational study was conducted in the Department of Transfusion Medicine at a tertiary care liver center from October 2018 to March 2019. The blood bank and patient records of cirrhotic patients admitted during the study period were retrieved and analyzed to determine the current transfusion practice.

Results:

A total of 992 cirrhotic patients were included in the study. Blood components were transfused to 402 (40.5%) patients. Sixty-nine (17.2%) patients were transfused to control/treat active bleeding, while 333 (82.8%) were transfused prophylactically. Packed red blood cells (65.4%) was the most commonly transfused blood component, followed by fresh frozen plasma (35.6%), among patients receiving transfusions (therapeutic & prophylactic). The mean pre-transfusion thresholds for: (i) packed red blood cell transfusion: hemoglobin less than 7 g/dL; (ii) fresh frozen plasma transfusion: international normalized ratio over 2.6; (iii) platelet concentrate transfusion: platelet count less than 40,700/µL, and; (iv) cryoprecipitate transfusion: fibrinogen less than 110 mg/dL. The average length of stay of the study population was 5 days (3–9.

Conclusion:

To conclude, 40.5% of our hospitalized cirrhotic patients were transfused, with the majority of the transfusions being prophylactic (82.8%). Separate guidelines are required for this patient population, as these patients have an altered hemostasis which responds differently to the transfusion of blood components.

Keywords:
Transfusion practice; Cirrhosis; Thresholds; Blood transfusion; Coagulopathy

Variables	All patients (n = 992)	Transfused (n = 402)	Non-transfused (n = 590)	p-Value
Age (mean ± S.D.)	51.1 ± 12.4 years	49.2 ± 12.1 years	52.4 ± 12.4 years	0.0001
Gender (n, %)
Male	840 (84.7%)	350 (87%)	490 (83%)	0.08
Cirrhosis etiology (n, %)
Ethanol	460 (46.4%)	214 (53.2%)	246 (41.7%)	0.0004
NASH	214 (21.6%)	81 (20.1%)	133 (22.5%)	0.36
Hepatitis B	97 (9.8%)	31 (7.7%)	66 (11.2%)	0.06
Hepatitis C	54 (5.4%)	23 (5.7%)	31 (5.3%)	0.78
Hepatitis B + Hepatitis C	5 (0.5%)	4 (1%)	1 (0.2%)	0.08
Primary biliary cirrhosis	1 (0.1%)	0	1 (0.2%)	0.36
Autoimmune hepatitis	16 (1.6%)	4 (1%)	12 (2%)	0.21
Primary sclerosing cholangitis	8 (0.8%)	3 (0.7%)	5 (0.8%)	0.85
Cryptogenic/others	137 (13.8%)	42 (10.4%)	95 (16.1%)	0.01
Reason for admission (n, %)
Decompensated cirrhosis^* * p = 0.13	603 (60.8%)	233 (58%)	370 (62.7%) 24 (4.6%)	0.13
GI bleeding	107 (10.8%)	80 (19.9%)	60 (10.2%)	<0.0001
Surgery/procedure	82 (8.3%)	22 (5.5%)	7 (1.2%)	0.008
Transplant assessment	14 (1.4%)	7 (1.7%)	12 (2%)	0.51
AKI	18 (1.8%)	6 (1.5%)	99 (16.8%)	0.56
Constitutional symptoms	151 (15.2%)	52 (12.9%)	15 (2.5%)	0.09
Others	17 (1.7%)	2 (0.5%)		0.01
Laboratory parameters (median; IQR)
Hemoglobin (g/dL)	9.9 (7.7–11.7)	7.4 (6.6–9.2)	10.9 (9.6–12.4)	0.0001
Total leukocyte count (/μL)	7.2 (5–11.7)	7.6 (4.7–12.3)	7.1 (5.2–11.1)	0.624
Platelet count (/μL)	88 (55–136)	64 (40.7–102)	104.5 (71–158)	0.0001
Prothrombin time (s)	18.1 (15.1–23.4)	21.3 (17–28.8)	16.8 (14.5–20.8)	0.0001
INR	1.73 (1.41–2.28)	2.06 (1.6–2.8)	1.59 (1.34–1.99)	0.0001
Fibrinogen (mg/dL)	131.7 (74.8–173.4)	103 (67.6–181.1)	126.5 (87.6–153)	0.983
Total bilirubin (mg/dL)	3.6 (1.6–10.8)	4.7 (2.2–12.5)	3 (1.4–8.9)	0.3
AST (IU/mL)	37 (25–59.7)	33 (23–54.7)	40 (26–66.7)	0.303
Albumin (g/dL)	2.5 (2.1–3)	2.4 (2–2.9)	2.6 (2.2–3.1)	0.006
S. Creatinine (mg/dL)	0.88 (0.63–1.38)	0.97 (0.66–1.7)	0.83 (0.61–1.18)	0.016
Child Pugh Score (n, %)
A	144 (14.5%)	26 (6.5%)	118 (20%)	<0.0001
B	332 (33.5%)	118 (29.4%)	214 (36.3%)	0.02
C	516 (52%)	258 (64.2%)	258 (43.7%)	<0.0001
Clinical outcomes
Length of stay (median, IQR)	5 days (3–9)	7 days (4–12)	4 days (3–7)	0.0001
In-hospital-mortality (n, %)	73 (7.3%)	54 (13.4%)	19 (3.2%)	<0.0001

Type of blood component transfused	Pre-transfusion triggers	Overall (n, %)	Bleeding patients (n, %)	Non-bleeding patients
Type of blood component transfused	Pre-transfusion triggers	Overall (n, %)	Bleeding patients (n, %)	Total (n, %)	Absence of active bleeding or procedure (n, %)	Pre-procedure %)	(n,
PRBC	Hb (g/dL)
	≤7	165 (62.7%)	26 (48.1%)	139 (66.5%)	134 (68.7%)	6 (42.9%)
	7.1–8	51 (19.4%)	11(20.4%)	40 (19.1%)	37 (19%)	2 (14.3%)
	8.1–9	22 (8.4%)	6 (11.1%)	16 (7.7%)	16 (8.2%)	0
	9.1–10	11(4.2%)	5 (9.3%)	6 (2.9%)	4 (2.1%)	2 (14.3%)
	≥10	14(5.3%)	6 (11.1%)	8 (3.8%)	4 (2.1%)	4 (28.6%)
FFP	INR
	≤1.5	8 (5.6%)	3 (11.5%)	5 (4.3%)	2 (3%)	3 (6%)
	1.5–2	45 (31.5%)	5 (19.2%)	40 (34.2%)	18 (26.9%)	22 (44%)
	≥2	83 (58%)	16 (61.5%)	67 (57.3%)	45 (67.2%)	22 (44%)
	Not reported	7 (4.9)	2 (7.7%)	5 (4.3%)	2 (3%)	3 (6%)
PC	PLT count (/ µ L)
	<50,000	54 (75%)	6 (42.9%)	48 (82.8%)	34 (79.1%)	14 (93.3%)
	≥50,000	18 (25%)	8 (57.1%)	10 (17.2%)	9 (20.9%)	1 (6.7%)
CP	Fibrinogen (mg/dL)
	≤100	7 (15.6%)	4 (21.1%)	4 (15.4%)	3 (13%)	1 (33.3%)
	101–200	7 (15.6%)	3 (15.8%)	3 (11.5%)	2 (8.7%)	1 (33.3%)
	201–250	0	0	0	0	0
	≥251	0	0	0	0	0
	Not reported	31 (68.9%)	12 (63.2%)	19 (73.1%)	18 (78.3%)	1 (33.3%)

Type of blood component transfused	Pre-transfusion triggers	Overall (mean ± S.D.)	Bleeding patients (mean ± S.D.)	Non-bleeding patients (mean ± S.D.)
PRBC	Hb (g/dL)	6.9 ± 1.6	7.3 ± 2.03	6.9 ± 1.5
FFP	INR	2.6 ± 1.25	2.9 ± 1.69	2.6 ± 1.12
PC	Platelet count (/µL)	40,700 ± 26,100	57,000 ± 24,200	36,800 ± 25,200
CP	Fibrinogen (mg/dL)	108.7 ± 441.9	101.2 ± 49.4	116.3 ± 35

Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH) R. Dr. Diogo de Faria, 775 cj 133, 04037-002, São Paulo / SP - Brasil - São Paulo - SP - Brazil
E-mail: htct@abhh.org.br

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[1] *Corresponding author at: Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India. E-mail address: meenubajpaii@gmail.com (M. Bajpai).