Blood transfusion represents the ‘treatment’ that we use most in our limited armamentarium of therapy for anemia in myelodysplastic syndromes (MDS). Although we have selected therapies that promote independence from transfusion – for example, erythropoietin, Revlimid (lenalidomide), and Vidaza (azacitidine) – these interventions eventually lose their beneficial effect and all patients return to blood transfusions once more.
Despite the widespread use of blood transfusions, do we know how best to use them for all patients? The simple answer is NO; there are no large clinical studies to inform our practice.
Many questions spring to mind, and I will discuss several of them here.
1. How do we decide on the trigger for transfusion in an individual patient – symptoms, hemoglobin concentration, or both?
In my view, provided that blood supply is not an issue, the decision to transfuse an individual patient should be determined primarily by their symptoms and by their lifestyle and/or professional requirements for an improvement in their level of hemoglobin, which is a protein found in red blood cells and an indicator of anemia.
Clearly, the patient whose mobility is so limited by arthritis that they are wheelchair-bound will not expect to become more mobile after transfusion, but he/she may wish to feel more alert and fall asleep less often. By contrast, the fell-runner who wishes to continue to run up hills needs a higher hemoglobin concentration to maintain their activity.
2. What is the optimal blood transfusion schedule for each patient – number of units of blood and how frequently?
Although most clinicians wish to do their best for patients, the nihilism that surrounds MDS and the busy clinics that include MDS patients result in transfusion by ‘rote’ as the most common approach; two units every three to four weeks is assumed to be fine for most patients. Clearly, this is not always so.
In addition, the benefit may vary from transfusion episode to episode. Many factors can impact on this, but the hemoglobin content of each unit is not standardized and each donor’s hemoglobin concentration could vary from 11.6 g/dl to 17.9 g/dl (the limits of the reference range for hemoglobin in the healthy population).
Adjusting lifestyle by the cycle of transfusion cannot be easy, and ‘Lady N’ describes eloquently the planning required when she was at her most anemic phase of the cycle.
Rarely do we suggest a ‘sliding scale’ for individual patients; for example, two units if their hemoglobin concentration is less than 9 g/dl, one unit if it is greater than 9 but less than 10 g/dl, etc.
The full article is located at The MDS Beacon