Red blood cell transfusion is associated with further bleeding and fresh-frozen plasma with mortality in nonvariceal upper gastrointestinal bleeding

BACKGROUND: Blood products are commonly transfused for patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). While concerns exist about further bleeding and mortality in subsets of patients receiving red blood cell (RBC) transfusion, the impact of non-RBC blood products has not previously been systematically investigated. The aim of the study was to investigate the associations between blood products transfusion, further bleeding, and mortality after acute NVUGIB. STUDY DESIGN AND METHODS: A retrospective cohort study examined further bleeding and 30-day and 1-year mortality in adult patients who underwent gastroscopy for suspected acute NVUGIB between 2008 and 2010 in three tertiary hospitals in Western Australia. Survival analysis was performed. RESULTS: A total of 2228 adults (63% male) with 2360 hospital admissions for NVUGIB met the inclusion criteria. Median age at presentation was 70 years (range, 19–99 years). Thirty-day mortality was 4.9% and 1-year mortality was 13.9%. Transfusion of 4 or more units of RBCs was associated with greater than 10 times the odds of further bleeding in patients with a hemoglobin level of more than 90 g/L (odds ratio, 11.9; 95% confidence interval [CI], 3.1-45.7; p ≤ 0.001), but was not associated with mortality. Administration of 5 or more units of fresh-frozen plasma (FFP) was associated with increased 30-day (hazard ratio, 2.8; 95% CI, 1.3-5.9; p = 0.008) and 1-year (hazard ratio, 2.6; 95% CI, 1.3-5.0; p = 0.005) mortality after adjusting for coagulopathy, comorbidity, Rockall score, and other covariates. CONCLUSION: In this large, multicenter study of NVUGIB, RBC transfusion was associated with further bleeding but not mortality, while FFP transfusion was associated with increased mortality in a subset of patients

An observational study of Donor Ex Vivo Lung Perfusion in UK lung transplantation: DEVELOP-UK

Background: Many patients awaiting lung transplantation die before a donor organ becomes available. Ex vivo lung perfusion (EVLP) allows initially unusable donor lungs to be assessed and reconditioned for clinical use. Objective: The objective of the Donor Ex Vivo Lung Perfusion in UK lung transplantation study was to evaluate the clinical effectiveness and cost-effectiveness of EVLP in increasing UK lung transplant activity. Design: A multicentre, unblinded, non-randomised, non-inferiority observational study to compare transplant outcomes between EVLP-assessed and standard donor lungs. Setting: Multicentre study involving all five UK officially designated NHS adult lung transplant centres. Participants: Patients aged ≥ 18 years with advanced lung disease accepted onto the lung transplant waiting list. Intervention: The study intervention was EVLP assessment of donor lungs before determining suitability for transplantation. Main outcome measures: The primary outcome measure was survival during the first 12 months following lung transplantation. Secondary outcome measures were patient-centred outcomes that are influenced by the effectiveness of lung transplantation and that contribute to the health-care costs. Results: Lungs from 53 donors unsuitable for standard transplant were assessed with EVLP, of which 18 (34%) were subsequently transplanted. A total of 184 participants received standard donor lungs. Owing to the early closure of the study, a non-inferiority analysis was not conducted. The Kaplan–Meier estimate of survival at 12 months was 0.67 [95% confidence interval (CI) 0.40 to 0.83] for the EVLP arm and 0.80 (95% CI 0.74 to 0.85) for the standard arm. The hazard ratio for overall 12-month survival in the EVLP arm relative to the standard arm was 1.96 (95% CI 0.83 to 4.67). Patients in the EVLP arm required ventilation for a longer period and stayed longer in an intensive therapy unit (ITU) than patients in the standard arm, but duration of overall hospital stay was similar in both groups. There was a higher rate of very early grade 3 primary graft dysfunction (PGD) in the EVLP arm, but rates of PGD did not differ between groups after 72 hours. The requirement for extracorporeal membrane oxygenation (ECMO) support was higher in the EVLP arm (7/18, 38.8%) than in the standard arm (6/184, 3.2%). There were no major differences in rates of chest radiograph abnormalities, infection, lung function or rejection by 12 months. The cost of EVLP transplants is approximately £35,000 higher than the cost of standard transplants, as a result of the cost of the EVLP procedure, and the increased ECMO use and ITU stay. Predictors of cost were quality of life on joining the waiting list, type of transplant and number of lungs transplanted. An exploratory model comparing a NHS lung transplant service that includes EVLP and standard lung transplants with one including only standard lung transplants resulted in an incremental cost-effectiveness ratio of £73,000. Interviews showed that patients had a good understanding of the need for, and the processes of, EVLP. If EVLP can increase the number of usable donor lungs and reduce waiting, it is likely to be acceptable to those waiting for lung transplantation. Study limitations include small numbers in the EVLP arm, limiting analysis to descriptive statistics and the EVLP protocol change during the study. Conclusions: Overall, one-third of donor lungs subjected to EVLP were deemed suitable for transplant. Estimated survival over 12 months was lower than in the standard group, but the data were also consistent with no difference in survival between groups. Patients receiving these additional transplants experience a higher rate of early graft injury and need for unplanned ECMO support, at increased cost. The small number of participants in the EVLP arm because of early study termination limits the robustness of these conclusions. The reason for the increased PGD rates, high ECMO requirement and possible differences in lung injury between EVLP protocols needs evaluation

Blood use in sub‐Saharan Africa: a systematic review of current data

Background: Data on the use of blood products in sub-Saharan Africa (SSA) are scarce. A systematic review of published data on blood utilization according to diagnosis in SSA was performed. Study design and methods: Studies published from January 2000 to June 2018 were searched in PubMed, Embase and African Index Medicus. Data were extracted and synthesized. The proportion of blood products used for different diagnostic categories is presented. Results: 37 studies representing 159,746 transfusions to 96,690 patients from 14 countries in SSA were included. Data from six of 37 studies were pooled to determine blood product use according to diagnosis. The primary diagnostic categories were pediatric malaria (20%), sickle cell anemia [SCA] (18%), obstetric hemorrhage (16%), and other causes of bleeding (16%). About 8%, 6% and 2% of products were used for other infections, cancer treatment, and surgery respectively. Overall, 58.5% of the products transfused were red blood cells, 31.7 % whole blood, 7.2% fresh frozen plasma, and 2.6% as platelets. Estimated blood product use per population in SSA was 5.3 transfusions per 1000 people, compared with 52 and 34 per thousand for Australia and United States respectively. Conclusion: This study provides a systematic attempt to quantify blood utilization for SSA. Blood products in SSA are used primarily for pediatric malaria, SCA, obstetric hemorrhage and other causes of bleeding. Studies such as this represent an important early step towards improving hemovigilance in SSA

What motivates men to donate blood? A systematic review of the evidence

Background and Objectives: Effective recruitment and retention of male donors are vital for the ongoing provision of blood products. Compared with females, male donors are less likely to be medically deferred or experience vasovagal reactions and are typically preferred for plasmapheresis donation in voluntary non‐remunerated settings. However, females outnumber males among donors aged under 40 years. This systematic review aimed to synthesize evidence and identify key motivators for blood donation among males to inform targeted recruitment/retention campaigns. Materials and Methods: Databases (e.g. EBSCOhost, Web of Science) were searched using terms (dona* OR dono*) AND (blood OR aphaeresis OR apheresis OR plasma* OR platelet* OR platlet*) in title AND (male OR gender OR sex OR female) AND (motivat* OR intention OR attitude OR behavi* OR predictor OR barrier OR deter*) NOT (organ OR sperm OR tissue OR autologous OR oocyte) in text. Two researchers independently systematically scanned quantitative, full‐text, English language, peer‐reviewed publications from 1990 to 2015 that examined males/females separately with outcomes of blood donation or self‐reported intention. Two additional researchers resolved discrepancies. Results: Among 28 identified articles, the most frequently cited motivators for male blood product donation were as follows: altruism; positive attitude towards incentives; health check(s); subjective norms. Altruism was less pronounced among males compared with females and was combined with ‘warm glow’ in novice males (impure altruism). Perceived health benefits and incentives (e.g. coffee mugs) were stronger motivators of males than females. Conclusion: Marketing campaigns for recruitment/retention of male donors should focus on identified motivators rather than take a ‘one‐size‐fits‐all’ approach