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Haemoglobin Increment by Red Blood Cells Transfusion in Cancer Patients with Anaemia

Authors:
  • Colonel Malek Medical College Manikganj

Abstract

Severe anaemia is usually treated with red blood cell (RBC) transfusion and in some cases moderate anaemia also requires transfusion. Traditionally one unit of red blood cells is transfused to increase the haemoglobin (Hb) level by 1 gm/dl, although no consensus guideline is available in our country. This study was done to see how much haemoglobin level was increased after transfusion of one unit of red blood cells in cancer patients with anaemia in our people. During the period of July 2012 to December 2012, 160 patients were studied in the Department of Transfusion Medicine of National Institute of Cancer Research and Hospital (NICRH), Mohakhali, Dhaka. All patients were aged >18 years of both sexes having a haemoglobin level of <10 gm/dl, and had no transfusion of platelets, plasma or colloid within 24 hours of red cells trunsfusion or with active bleeding or drain loss. The average increment of haemoglobin level was 0.74 gm/dl (0.74+0.11) gm/dl for each unit of red blood cells transfusion. This rise of haemoglobin level was different from the traditional calculation which was statistically significant (p<0.01). The traditional calculation for correction of anaemia by red blood cell transfusion is not suitable for the people of our country.
Original
Summary
Severe unsemia is usually treuted with red blood
cell (RBC) trunsfusion und in some csses
moderate ansemis also requires transfusion.
Traditionally one anit of red blood cells is
transfused to increuse the hemoglobin (Hb) level
by I gm/dl, although no consensus guideline is
uvsiluble in our country. This study was done to
see how ntuch hemoglobin level wss increased
after transfusion of one unit of red blood cells in
csncer putients witlr anaentiu in our people.
During the period of July 2012 to December
2012, 160 patients were studied in the
D e
p a rt m e n t oJ' Tra n sfu s i o n M e d i c i n e oJ' N ati o n a I
Institute of Cancer Resesrch and Hospital
(NICRH), Mohakhali, Dhuku. All patients were
aged >18 years of both sexes ltuving s
haemoglobin level of <10 gm/dl, snd hud no
transJusion oJ'platelets, plasmu or colloid within
24 hours oJ'red cells trunsJusion or with active
bleeding or drsin loss. The sverage increment of
haemoglobin level was 0.74 gm/dl (0.74+0.11)
gm/dl Jbr esch unit oJ' red blood cells
transJusion. This rise oJ haemoglobin level wss
different from the trsditionsl calculstion which
wus statistically signiJicant (p<0.01). The
traditional culculation for correction of unaemia
bv red blood cell transfusion is not suituble for
the people oJ'our country.
Key words
.{naemia; Red cell transfusion; Haemoglobin.
L{ssoc jalc Plot'cssol ol Paediatric Oncology
\ational Institute of Cancer Resealch and Hospital (NICRH)Dhaka
I .\ssociate Professor of Transfusion Medicine
\.uiontl Institute of Canccr Research and Hosprtal (NICRH) Dhaka
-: \ssistant Prof'essor of Haematology
\.,nonrl Insrirurc olCancer Research and Hospital (NICRH) Dhaka
- \\sislant Prolessor of Haetnatology
\.,::,.,nrl lnstitute olC'ancer Resealch and Hosprtal (NICRH) Dhaka
( orrespondence : Dr. Manttaz Begum
E nt u i l : begunt. cl r. nru n ta:Qggtu a i L cotn
Cell .017217t5408
JCMCTA 2014 ;25 (2) :21 - 25
HAEMOGLOBIN INCREMENT BY RED BLOOD CELLS
TRANSFUSION IN CANCER PATIENTS WITH ANAEMIA
Marntaz Begurnl Laila Arjumand Banu2 Md Kamrul Hasans Naima Islam4
Introduction
Anaemia is a common problem in cancer patients.
Its prevalence and incidence are widely variable
ranging frorn 30%o to 90oh [1-5]. Anaernia is
present in 48o/o of patients with solid tumour
befcre radiotherapy and in 57%o patients at the end
of the therapy [6]. The important causes of
anaemia in cancer patients are decreased
erythropoiesis due to nutritional deficiencies, bone
lnarrow infiltration by tumour cells and marrow
suppression by anticancer treatment, and blood
loss from the tumor or surgery, and also hemolysis
[7,8]. The presence of anaemia causes decreased
response to radiotherapy and increased toxicity to
chemotherapy 19-121. Anaemia also shortens the
life expectancy in cancer patients [3]. Therefore,
correction of anaemia is essential for appropriate
anticancer therapy. Usually rnoderate to severe
anaemia are treated by transfusion of red blood
cells. EORTC guidelines mention that patients
with hemoglobin levels of less than 9 g/dl should
be evaluated for the need of transfusions [4]. The
ASH/ASCO guidelines suggest that blood
transfusions may be an option for the corection of
anaemia associated with chemotherapy when
hemoglobin levels are less than 10 g/dl [5]. ln
some cases. rnild anaemia also treated by
transfusion depending on clinical condition e.g.
organ ischemia or inadequate oxygenation. actual
bleeding etc.
General guideline for red blood transfusion is as
follows [l6].
If Hb> l0gm/dl. red cells are rarely needed
If Hb <5gm/dl, red cells are usually needed,
If Hb 5- l0 gm/dl, red cells transfusion
requirement is detennined by additional clinical
conditions as described above.
Usually one unit of red cells increases the Hb level
by I g/dl- in an adult patient [17-191. This Hb
increment we adopted from different studies and
institutionalguidelines, but this method of calculation
2t
Original
is not evidence based and there is no such study
for the Bangladeshi people. Inappropriate
calculation of red cell volume for transfusion
causes inaccurate anaemia correction and
increases the risk of multiple transfusions,
additional cost and resource use. Assessment of
haemoglobin level after transfusion of every unit
of red blood cells should help us to calculate
haemoglobin increment in our people and thus we
can develop a formula for red blood cells
translusion for our patients.
This study was conducted to know how much
haemoglobin is raised after transfusion of I unit
(250+30 ml) red blood cells in cancer patient with
anaemia.
Material & methods
This was an observational study, done in the
Department of Transfusion Medicine of National
Institute of Cancer Research and Hospital,
Mohakhali, Dhaka, during the period of July 2012
to December 2012 after obtaining a full ethical
permission. A total of 160 cancer patients with an
age of >18 years of both sexes having a
haemoglobin level of <10 gm/dl were included in
this study. Haemoglobin level was estimated just
before transfusion and one hour after completion
of red cell transfusion. Patients who did not give
consent or had received infusion of colloid,
plasma or platelets within 24 hours or had active
bleeding or drain loss were excluded from the
study. If any reaction or any problem occurred in
patients during data collection period they were
not include in our study. Persons with
haemoglobin level 12 gmldl were excluded from
donation.
Standard operating procedures were followed for
blood donation and transfusion. Before
transfusion clinical condition of every patient was
monitored. Haemoglobin estimation was done by
haemoglobin Colour Scale (HCS) method. From
each participating person a capillary blood sample
were obtained by finger prick with a single-use
lancet after disinfection with alcohol, drying and
removal of the first drop of blood. The drop of
blood was absorbed onto a hlter paper lest strip.
After waiting about 30 seconds the colour of the
JCMCTA 2014 ;25 (2) :21 - 25
blood spot was matched against the scale colour
standards provided with HCS. The shades
correspond to haemoglobin levels of 4, 6,8, 10, l2
and 14 g dl.
Data were collected in a structured data collection
form. The data were analyzed and necessary tables
were made using SPSS for Windows l7 version.
Continuous data were expressed as mean + SD,
categorical data were expressed as number and
percentage. Paired T-test was done between pre
and post transfusion haemoglobin level, one
sample T test was done to see the statistical
significance of haemoglobin rise after transfusion
and ANOVA was done to see the influence of
cancer type on Hb increment. P<0.05 was
considered signifi cant.
Results
Among the 160 patients, male were 57 .5%
(921160) and female were 42.5oh (68/160) (Fig l).
Minimum age of the patient was l8 years and
maximum age was 76 years with a mean was
48.84 (+14.51) years. Minimum weight was 20 kg
and maximum weight was 72 kg with a mean of
4s.21 (+10.6) kg (Table I).
The pre transfusion mean haemoglobin was 6.33
(+0.99) gm/dl with a minimum of 4.5 gm/dl and a
maximum of 9.7 gm/dl. The mean volume of
transfused red cells was 244.30 (+10.08) ml. The
mean duration of transfusion was 3.3 (+0.26)
hours with minimum 3 hours and maximum 4
hours. The mean post transfusion haemoglobin
level was 7.08 (+1.02) gm/dl with minimum of
5.35 gm/dl and maximum of 10.60 gm/dl. The
mean haemoglobin increment after transfusion of
red cells was 0.74 (+0.1 I ) gm/dl (Table II).
The difference between pre-transfusion and post-
transfusion haemoglobin level was significant
(Table III).
Difference between the increment in haemoglobin
after transfusion of one unit of red blood in this
study and the traditional value was significant
(Table IV).
The cancer types that needed transfusion in our
study were Ca. lung, Ca. Cervix, Ca. Breast, Acute
22
Original
Myeloid Leukaemia, Acute Lymphoblastic
Leukaemia, Ca. Oesophagus, Ca. Tongue and
Ewing Sarcoma (Table V). However, statically
haemoglobin increment was not influenced by
cancer type (Table Vl).
u Male ,: Female
Fig I : Gender distribution of the patient
Table I : Age and weight of the patients (n- 1 60)
Variable Range Mean
Age (in years) l8-76 48.84 14.51
Weight (in kg) 20-72 45.2t ]0 6
Table II : Ple and Post transfusion Haemoglobin level
with Hb increment and transfused red cell volume
Variable Mean SD
JCMCTA 2014 :25 (2) : 21 - 25
TableV : Common Cancer type those required
transfusion
Type ofCancer: Frequency P:.glt l
Ca lung
Ca cervix
Ca breast
AML
ALL
Ca esophagus
Ca tongue
Ewing sarcorra
Osteosarcoma
Others
Total
36
2t
18
t4
l3
ll
l0
6
4
27
160
22.5
l3. l
lt.3
8.8
8.1
6.9
6.3
3.8
2.5
16.9
100.0
Tabte VI : Conelation of Haernoglobin increment
and Cancer types.
SD
6.33 .99
7.08 t.02
0.74 0.1 I
Haemoglobin
i'lggTgnr| lgean Square F ,-"".1
Pre transfusion Hb gm/dl
Post transfusion Hb grn/dl
Hb increment 1gm dl)*
Volume of red blood cells
transfused (in ml) 244.00 10.08
* Post transfusion rninus pre transfusion
Table III : Pre transfusion and post transfusion
haemoglobin level
Variable Number
Pre transfusion Mean P value
Between Groups
Within Groups
.007 0.513 0.863
.013
Discussion
Anaelnia impairs the quality of life of the cancer
patients [20]. Red blood cell transfusion is the
n-rost reliable rnethod of treatment of anaernia
especially when anaemia is moderate to severe.
One study showed that 52.7on of the patients
received red cell transfusion when there was Hb
<9.0 grn/dl [21]. The use of erythropoiesis
stimulating agents (ESA) epoetin or darbepoetin
is recommended as a treatrnent option and
considered for patients with chemotherapy-
associated anaemia when haemoglobin
concentration has decreased to less than 10 gidl.
to decrease transfusions but evidencc showing
that ESA use is associated with a statistically
significant increased risk of rnortality and venous
thromboembolism [22]. For this reason use of
ESA therapy should be based on clinical
judgment of patients' individual risks and
benefits.
Red blood cells transfusion rnay cause sorne
adverse reactior.r. Among these trarrsfusion
associated haer-nolytic reaction, infection and even
Hb gm/dl 160
Post transfusion
Hb gm/dl 160
6.33
7.08
<0.01
Table IV : Hb increment after one unit of RBC
trartslusion
Hb increment Mean P-value
In tladitional rnethod
In ihis study 1.00
0.14
23
<.001
Original
circulatory overload are remarkable. A study
conducted in 60 US medical centres between
1995 and 2003 found 7 .2o/o cancer patient with
anaemia receiving red cell transfusion developed
venous and 5.2oh patients developed arterial
thromboembolism 1231. So appropriate
calculation of red blood cell for transfusion is a
vital matter.
Usually patients wrth haematological
malignancies need transfusion fi'equently but in
our study patients with ca. lung, ca. cervix and ca.
breast were more in number. The reason was
when any patients develop anaemia during
anticancer therapy they usually transfused in the
outpatient department and we consider OPD for
collecting patients for the study. Among the study
population 87 patients were under chemotherapy,
3l were under radiotherapy and 42 were under
both the chemo and radiotherapy.
In the current study, male patients (57.5%) were
more than female. This finding may be due to
more number of rnale patients attending NICRH
in cornparison to female and it was consistent
with finding of cancer registry of NICRH [24].
We estimated haernoglobin level of every patient
before and I hour after completion of transfusion
because the study was done in the outpatient
department and a study shows that the
haemoglobin rise at 1,2 and 24 hours of red cell
transfusion were same [25]. Moreover, cancer
should have no effect on haemoglobin change
within this short period. Also statistically
haemoglobin increment was not influenced by
cancer type in our study.
The post-transfusion haemoglobin rise for one
unit of red cells was 0.74+0.1 I gm/dl was not
consistent with studies that showed the Hb
increment were I gm/dl [8,26].
We excluded patients with blood transfusion
reaction in our study. For this reason no
infonnation was provided regarding transfusion
reaction.
Conclusion
After transfusion of one unit of red blood cells,
haemoglobin level was raised but this increment of
haemoglobin (0.74 + 0.I I gm/dl1 was much lower
JCMCTA 2014 :25 (2) :21 - 25
than the value we used, i.e. I gm/dl/per unit of red
blood cells transfusion. Therefore. the traditional
calculation for correction of anaemia in cancer
by red cell transfusion is not suitable for the
people of our country. This study was conducted
in a single centre with small number of patients.
Further multi-centre study in our country with
large number of cases with longer duration can
explore rnore reliable and accurate inference.
Disclosure
All the authors declared no cornpeting interest.
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Clinical trials and surveys have shown that a majority of patients with cancer have low hemoglobin levels as a result of the disease and/or treatment. Clinical trials also have shown that the impact of anemia may be more insidious and far-reaching than generally appreciated. Specifically, studies have shown that low hemoglobin levels have significant impact on treatment outcomes, including survival. The mechanisms by which treatment efficacy and survival are compromised have not been fully elucidated but may include cellular compromise (eg, impaired tumor oxygenation), or more general patient compromise (eg, decreased quality of life and treatment delivery). Recent studies have suggested that increasing hemoglobin levels with recombinant human erythropoietin (r-HuEPO, epoetin alfa) have resulted in better outcomes following radiotherapy, chemotherapy, and the combined-treatment modality.
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Anemia is common in patients with cancer and is a frequent complication of myelosuppressive chemotherapy. In this study, we investigated the incidence and severity of chemotherapy-induced anemia caused by the most common chemotherapy regimens, including the new generation of chemotherapeutic agents, used in the treatment of the major nonmyeloid malignancies in adults. Five hundred fifty-two patients with histologically proven carcinoma originating from breast (n = 165), lung (n = 128), colon (n = 75), ovary (n = 84), and malignant lymphoma (n = 100) were included in this study. Hemoglobin levels for each patient were measured with an automatic counter during both pretreatment and before each chemotherapy cycle during therapy. To document the incidence of anemia, the National Cancer Institute grading system was used. Before chemotherapy, 44% of patients with breast carcinoma had anemia. There was a 16% increase in the incidence of anemia after chemotherapy. Severe anemia was observed in less than 1% of patients. No difference was found in the incidence of anemia between the fluorouracil, doxorubicin, cyclophosphamide (FAC) and cyclophosphamide, methotrexate, fluorouracil (CMF) regimens used in the adjuvant setting. However, single-agent chemotherapy with newer generation caused more anemia when compared with the FAC regimen (p < 0.005). Chemotherapy resulted in a significant decrease in hemoglobin levels when compared with pretreatment values in patients with lung cancer (p < 0.001). During treatment, the increase in the incidence of grade II anemia was associated with a parallel decrease in the incidence of grade I anemia. The incidence of severe anemia did not exceed 15%. The incidence of anemia was equivalent in both patients with small-cell lung cancer and those with non-small-cell lung cancer treated with the etoposide and cisplatin (EP) combination. Seventy-one percent of patients with colon cancer had anemia before initiation of chemotherapy. No difference was observed in posttreatment hemoglobin values compared with pretreatment values. Patients treated with irinotecan and fluorouracil and leucovorin (FUFA) combination showed similar rates of anemia. Incidence of anemia in patients with ovarian cancer at admission was 68%. Chemotherapy resulted in a prominent increase in incidence of anemia, which increased to 91.5%. There was an increase in grade II anemia, which corresponded to the decrease in grade I anemia. Less than 10% of patients developed severe anemia. No difference in the incidence of anemia was observed in patients with ovarian cancer treated with either cisplatin and cyclophosphamide or cisplatin combination. Showing a high incidence of anemia (82%) at presentation, hemoglobin levels in patients with malignant lymphoma were unaltered with chemotherapy. Severe anemia occurred in less than 3% of patients. There was a higher incidence of anemia in patients with non-Hodgkin's lymphoma receiving the cyclophosphamide, epirubicin, vincristine, prednisone (CEOP) regimen in contrast to patients with Hodgkin's lymphoma treated with the doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) combination. There was a prominent decline in the hemoglobin levels with cisplatin-based combinations in contrast to combinations including noncisplatin agents (p < 0.001). In this study, we have observed equivalent rates of treatment-related anemia when compared with previous data in patients with specific tumor types. The incidence of pretreatment anemia was high in various malignancies. The mechanisms underlying the propensity for a higher risk of pretreatment anemia in patients with malignant disorders and its influence on the outcome has to be elucidated by further population-based and molecular studies.
Article
Anemia is common in patients with cancer. This systematic literature review of reports published in 1966 through February 2003 identified the prevalence of anemia in specific cancers and assessed the impact of anemia on survival and quality of life (QOL). Studies about chemotherapy-induced anemia were excluded. Anemia prevalence varied widely; most studies found that between 30% and 90% of patients with cancer had anemia. Prevalence was affected strongly by the definition of anemia: 7% of patients with Hodgkin disease had anemia when the condition was defined as a hemoglobin level <90.0 g/L; as many as 86% of patients had anemia when it was defined as a hemoglobin value <110.0 g/L. Prevalence varied by cancer type and disease stage: 40% of patients with early-stage colon tumors and nearly 80% of patients with advanced disease had anemia. Patients with anemia had poorer survival and local tumor control than did their nonanemic counterparts in 15 of 18 studies. In 8 of 12 studies, patients without anemia (most treated with epoetin) needed fewer transfusions. QOL was positively correlated with hemoglobin levels in 15 of 16 studies. There was no significant difference in treatment toxicity between patients with and without anemia. Tumor hypoxia, which has been associated with resistance to radiation therapy and chemotherapy, may stimulate angiogenesis, leading to poor local control of tumors and increased morbidity and mortality. Treatment of anemia may have a significant impact on patient survival and QOL. However, a standard definition of anemia is needed, as is research about the effect of anemia on cancer progression.