Platelet transfusion in adults: An update.

Many patients worldwide receive platelet components (PCs) through the transfusion of diverse types of blood components. PC transfusions are essential for the treatment of central thrombocytopenia of diverse causes, and such treatment is beneficial in patients at risk of severe bleeding. PC transfusions account for almost 10% of all the blood components supplied by blood services, but they are associated with about 3.25 times as many severe reactions (attributable to transfusion) than red blood cell transfusions after stringent in-process leukoreduction to less than 106 residual cells per blood component. PCs are not homogeneous, due to the considerable differences between donors. Furthermore, the modes of PC collection and preparation, the safety precautions taken to limit either the most common (allergic-type reactions and febrile non-hemolytic reactions) or the most severe (bacterial contamination, pulmonary lesions) adverse reactions, and storage and conservation methods can all result in so-called PC "storage lesions". Some storage lesions affect PC quality, with implications for patient outcome. Good transfusion practices should result in higher levels of platelet recovery and efficacy, and lower complication rates. These practices include a matching of tissue ABH antigens whenever possible, and of platelet HLA (and, to a lesser extent, HPA) antigens in immunization situations. This review provides an overview of all the available information relating to platelet transfusion, from donor and donation to bedside transfusion, and considers the impact of the measures applied to increase transfusion efficacy while improving safety and preventing transfusion inefficacy and refractoriness. It also considers alternatives to platelet component (PC) transfusion.

Transfusion at the border of the "intention-to-treat", in the very aged person and in palliative care: A debate.

In both palliative care and in the very aged person i.e. at the end of life, transfusion aims at bringing supportive care; it has indeed no intention to treat. It can occasionally be compassionate as to bring oxygen to a patient or a resident in nursing home wishing to enjoy some exercise or entertainment. Transfusion in this condition is not consensual, for reasons that are medical and/or societal. The present essay aims at discussing the main options to provide transfusion in such extreme, though non-exceptional, conditions.

International collaboration for blood safety: The French-African experience.

Blood safety is a non-negotiable issue worldwide, specifies the World Health Organization (WHO). Africa is both an entity and a multiplicity of situations within and cross-borders. Indeed, most African countries have recent borders and political organizations, after gaining independence in the 60's. Many such countries have maintained various types of links and cooperation programs with former European countries of influence, e.g. France and Belgium among others, which is the case for several countries from the francophone Central and West Africa. Besides, borders do not delineate ethnic groups as many of them migrate, with spread North to South and East to West across several countries, each having representations, ethnologically speaking. Transfusion is an essential supportive healthcare that requires medicine, technicity and logistics. Cooperation can be provided to Francophone Africa though at the expense of recruiting donors upon criteria that do not completely overlap with e.g. those put forward in France and other high-income countries, despite WHO claims for the universal model of Voluntary Non-Remunerated Blood Donation system. Next, the patient profile in intertropical Africa-of which the various francophone African countries-stringently differs from the profile now seen in France, with its younger (but strongly social network-connected) populations and the importance of anemia of all causes but frequently infectious in nature. The frequency of antigens defining blood groups also significantly differs from that in France and the rest of Europa. Last, the carriage of blood transmissible infectious pathogens in sick but also apparently healthy populations seriously complicates the build up of suitable blood component inventory. In the present review, we discuss the universality of blood donation, the specificities of inter-continent cooperation and report on experiences of such cooperation. The French Blood Establishment EFS has taken over earlier initiatives of regional blood services and provides technology and scientific transfer and support to many countries for several decades; the National Institute for Blood transfusion, an education and research institute, has set up collaborative research in several domains but mostly in the domain of blood transmissible infections. We next also present a theoretical view of support named ALEASE, that can be pursued, based on collaborative experiences carried out in the Mediterranean Northern and Eastern areas. ALEASE promotes benchmark between participants. If there is general agreement that cooperation between economically wealthy countries and low-income, developing, countries in the domain of blood and blood transfusion safety, promotion of blood donation, blood component manufacturing, transfusion technology, hemovigilance, etc., tools to achieve this goal can be periodically reviewed based on specific needs for countries and professionals. That also comprise of adapted, sometimes specific, education programs.

Review of indications for immunoglobulin (IG) use: Narrowing the gap between supply and demand.

Cellular blood components and plasma-derived medicinal products (PDMPs) are obtained from blood donated by volunteers. In a growing number of countries, in line with World Health Organization advice issued since the mid-1970s, donors are not remunerated. In recent decades, considerable efforts have been made to restrict the indications for labile blood components to those based on evidence, to ensure efficacy and safety. By contrast, the producers of PDMPs have developed pathogen reduction techniques for inactivating the microorganisms in (pooled) plasma, but little attention has been paid to the pertinence of the clinical indications for these products. The use of blood, and of erythrocytes in particular, has declined by almost 40%, but the use of immunoglobulins (IG) tripled between 2004 and 2018, making it necessary to pay donors to obtain sufficient blood to meet the market demand for these products. We analyzed the reasons for this increase to unsustainable levels of use, by investigating (practice) guidelines, recommendations, Cochrane data analyses and systematic reviews for clinical indications for IG over time. We found no new evidence explaining the huge increase up to 2018 or the predicted 5-7% yearly annual increase until 2024. For some former evidence-based indications, biologics have largely replaced IG, but the administration of IG for doubtful indications (up to 40%) has not decreased in recent decades. The main development since 2004 is that IG use in Europe has become market-driven rather than evidence-guided. As transfusion specialists and blood therapists, we must raise the alarm that this situation is likely to continue in the absence of good clinical studies determining the place of IG alongside other treatments, and for as long as market profitability remains the dominant driving force. We discuss here approaches for reversing this trend and moving towards European self-sufficiency through non-remunerated voluntary blood donation.

Transfusion medicine: Overtime paradigm changes and emerging paradoxes.

This essay aims to discuss some aspects of blood transfusion in the perspective of the changes that occurred over time as well as modifications of the paradigms that transformed the activities and the organization of blood transfusion services. Without specific knowledge, pioneers envisioned precision and personalized medicine, rendering transfusion medicine operational. Transfusion medicine is like The Picture of Dorian Grey: always young despite being old and sometimes appearing old-fashioned. Over the years, the transfusion medicine discipline has evolved, and major progress has been achieved, despite some troublesome periods (for example, the tainted blood scandal, and-at the time being-the offending plasma market and the selling of human parts). Transfusion medicine has at all times implemented the rapidly developing biomedical technologies to secure blood components. The safety of blood components has now reached an exceptional level in economically wealthy countries, especially compared to other health care disciplines. Strengthening of the safety has mandated that blood donors and recipients are unrelated, an issue which has eased preservation and fractionation practices; blood is no longer arm-to-arm transfused and neither is whole blood, the commonest component. However, it is interesting to note that a revival is occurring as whole blood is back on stage for certain specific indications, which is one among the many paradoxes encountered while studying this discipline.

Blood, perceptions, resource and ownership: When transfusion illustrates the complexity.

Blood is apart from the rest of the tissues as this fluid is overseen by basic and applied life and humanistic sciences. Blood is the essence of human functioning. It is the object of one of the most commonly known cancers, leukemia. It is life-saving in transfusion - a property that also gives blood a special credit and questions blood as a valuable merchandise or as no ones' property but common good. But blood is also scandalous after the tainted blood affair in the 1980s and 1990s. Blood is further inseparable from most religious practices, both forefront and hidden (magic cults). It is frightening as it is versed in legitimate and illegitimate combats; it is poured to compensate offenses or debts in many civilizations. Any time blood comes forefront, rationale science leaves it to irrational digressions. Even the very same life-saving transfusion, is beaten by groups of opponents on religious grounds. Further, at a time blood cells and molecules are scrutinized, no one can claim having a complete understanding of what blood is, off the vasculature, as - to study it - one has to alter it. The study of blood is fascinating for all colleges of an academy and not many topics can share this property: chemists, physicists, geneticists, physiologists, medical doctors, philosophers, ethicists, theologians, artists, historicists, anthropologists, sociologists, etc. have all contributed to depict different, specific, aspects of blood. The present review aims at merging different aspects of blood to give pathophysiologists a platform to better understand fears and hopes related to this special tissue, when dealing with patients of theirs.

Residents' knowledge in transfusion medicine and educational programs: A pilot study.

BACKGROUND: Residents' knowledge in transfusion medicine significantly impacts the optimal use of blood and patient safety. Little is known regarding this topic in France in particular. The objectives were to evaluate their basic knowledge, to determine whether the objectives of the curricula were attained and subsequently to suggest ways for improvement. METHODS: A cross-sectional study was conducted on 50 first year medical and surgical specialty residents rotating in a French university hospital. RESULTS: Major gaps in the knowledge were noted among residents of various specialties, equally between those with low and sustained transfusion practice. The majority of these young doctors expressed difficulties in prescribing and handling transfusions, identifying and managing its complications and understanding their responsibilities. The roles of hemovigilance practitioners were further somehow unclear for participants. CONCLUSION: Given these results, action plans appear needed to limit consequences. A special transfusion medicine educational program should be added to the currently available medical education curriculum in order to ensure physicians have adequate knowledge of transfusion basics; at least a practical assisted situation during residency would be of valuable interest.

Cytokines and related molecules, and adverse reactions related to platelet concentrate transfusions.

Platelet transfusion is a safe process, but during or after the process the recipient may experience an adverse reaction and occasionally a serious adverse reaction (SAR). Platelet concentrate transfusion may be liable for significant absence of beneficial response. Danger may manifest clinically or biologically; in the latter case, manifestations are frequently an absence of the expected response to the blood component by the recipient. Blood platelets exert roles in inflammation, especially through the immunomodulator complex CD40/CD40L (sCD40L). In this review, we concentrate on the inflammatory potential of platelets and their participation to SARs in transfusion.

How to reposition the benefice-risk balance to safely transfuse patients in non-vital situations?

It appears that the vast majority of review articles on transfusion deal with complications rather than benefits of this supportive therapy. However, deduced from reports compiled by hemovigilance systems, the majority of transfusion procedures do not lead to complications; rather, the majority of prescriptions of blood components generate measurable benefits in the transfused patient. This short review attempts to analyze the causes for such a discrepancy between benefits and complications in the literature and in the everyday life in wards and introduces the role of Patient Blood Management in this understanding.

The plasma supply in France.

Contrary to economically comparable countries, France has had a versatile policy to process and manufacture therapeutic plasma, and to apply safety measures. This has principally affected the origin of plasma (whole blood supernatant versus apheresis), and the application or not of a chemical process. At the time being, the civilian and Army Forces blood establishments produce more than 99% of the plasma issued for patients in need; safety means consist in a large part of quarantine and, to a lesser extent, to a pathogen reduction technology process (Amotosalen-HCl-UVA). The blood establishments ship plasma to the national manufacturer of blood derivatives. Plasma in France is strictly within the Voluntary Non-Remunerated pathway with no breach to this principle to be expected for both labile components and source plasma. The constant hemovigilance allows reflection to make policies evolving, with respect to safety measures particularly to reduce cases of allergy.

Blood donations mode: Assessment of the Lebanese model.

Voluntary non-remunerated donations remain the cornerstone for a safe and sustainable blood supply. According to the World Health Organization and other international scientific committees, all nations must switch their system of blood collection to voluntary non-remunerated donation. Several other types of blood donations still exist nowadays that will be discussed. Lebanon, similarly to other developing countries, is struggling to achieve 100% voluntary non-remunerated donations for the many existing social, demographic, cultural and economic problems. Replacement donations remain the predominant type, which creates huge burden on both hospital blood banks and patient families. Despite the limited resources, some improvements have been made recently in this field and Lebanon seems to be on the road of achieving 100% voluntary non-remunerated blood donation as requested by the World Health Organization. The Lebanese experience is worth sharing so that neighbouring countries facing similar problems could benefit from it.

Plasma for direct therapeutic use, for today and tomorrow: A short critical overview.

Plasma for direct therapeutic use is a fast-evolving blood component in terms of its production and presentation. More than a dozen forms are available worldwide, which is often overlooked since most countries apply policies making only one or very few forms available for treating patients in need. It is most often reserved for the same three clinical indications, i.e. overall clotting-factor deficiency, reversal of vitamin K antagonists in the context of active bleeding or prior to urgent surgery, and therapeutic plasma exchange. The level of evidence is often less robust than generally acknowledged for such major indications while novel indications are tending to emerge in medical and trauma settings. This short review explores classical views and new prospects opened up by novel presentations and statuses for therapeutic plasma.

How to mitigate the risk of inducing transfusion-associated adverse reactions.

Transfusion has become extremely safe but can still be associated with adverse reactions. Some adverse reactions can be mitigated by applying measures to donor selection, the process of separating blood components as well as hospital-based procedures consisting in matching the donor and the recipient; special attention is given to optimizing the best fit between the component and the beneficiary, which is not only an immuno-hematological challenge (fresh versus old blood, testing for certain viruses such as CMV, parvovirus B19, etc.). Considerable progress has also been achieved to strengthen the overall quality and safety of the whole transfusion chain. Guidelines and recommendations have resulted in substantial progress, and the recent revisiting of patients as part of a more holistic approach has enabled blood management programs to be created. Such programs, when wisely applied in a context of optimal blood use, reinforce patient safety; they enhance hospital recognition of transfusion and hemovigilance specialists as useful players acting in the interests of patients in full compliance with hospital budgets. This review considers the step-by-step processes that reinforce transfusion safety and identifies hurdles that cannot yet be properly addressed; it proposes steps for further progress, in light of personalized medicine.