[page 30] [Thalassemia Reports 2017; 7:6821] Improving transfusion practice in transfusion dependent thalassaemia patients Chathupa Wickremaarachchi, 1,2 Elizabeth McGill, 1 Annmarie Bosco, 1,2 Giselle Kidson-Gerber 1,2 1 Department of Haematology, Prince of Wales Hospital, Sydney; 2 Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia Abstract The aim of this study was to improve current transfusion practice in transfusion- dependent thalassaemia patients by deter- mining whether safe transition from triple- washed red cells (TWRC) to leucodepleted red cells (LDRC), increasing transfusion rates, reducing the use of frusemide and cre- ating uniform practice across patients is possible. In patients receiving regular trans- fusions (50), triple-washed red blood cells were changed to LDRC, transfusion rates were increased to 5 mL/kg/h (in line with the Cooley’s Foundation guidelines) to a maximum of 300 mL/h and frusemide was ceased. Medical review occurred at comple- tion of the transfusion. Of the 20 patients on TWRC, 18 were transitioned to leucode- pleted red cells (90%). Recurrent allergic reactions in 2 patients required re-institu- tion of TWRC. 7 of the 8 patients on regular frusemide ceased this practice with no doc- umented transfusion-related fluid overload. One patient refused. Of the eligible 50 patients, 20 patients (40%) were increased to the maximum transfusion rate of 300 mLs/h; 6 (12%) increased rate but refused to go to the maximum; 9 (18%) refused a change in practice and 15 (30%) were already at the maximum rate. There was only one documented transfusion reaction (palpitations) however this patient was able to tolerate a higher transfusion rate on sub- sequent transfusions. Thalassemia patients on TWRC were safely transitioned to LDRC. Transfusion rates were safely increased, with a calculated reduction in day-stay bed time of 17.45 h per month. This confirms a guideline of 5 mL/kg/h for transfusion-dependant thalassaemia patients with preserved cardiac function is well tol- erated and may be translated to other cen- tres worldwide. Introduction Thalassaemia is an autosomal recessive inherited haemoglobinopathy, which results in abnormal haemoglobin formation. Those with severe genetic defects are transfusion- dependent either from early childhood (tha- lassaemia major) or later in life (thalas- saemia intermedia). Two to four units of packed red blood cells are usually trans- fused every 3 to 4 weeks. Previously, in the attempt to reduce the potential for alloim- munisation, thalassemia patients may have received triple-washed red cells. In November 2008, the national blood service introduced universal leucodepletion of red cells in addition to change in manufacturing to reduce the plasma volume to <10 mL/red cell bag - changes which potentially miti- gated the need for TWRC. Attendance at transfusion, including travel to the centre, is a significant time requirement, and so as we optimise the medical management, we also aim to opti- mise our patients’ capacity to function in everyday life without compromise to safety. The biggest modifiable factor in this time requirement is the rate at which blood prod- ucts are transfused. Although the American-based Cooley’s Anaemia Foundation recommends transfus- ing patients with preserved cardiac function at a rate of 5 mL/kg/h, 1 the most recent international thalassaemia guidelines are less clear, stating transfusion of 2-3 units should take approximately 3-4 h. 2 Correspondence with other thalas- saemia centres in both the United Kingdom and Australia showed a wide variation in practice (Greely C, Transfusion practices at Monash Health, Victoria, 2015; and Prescot E, Transfusion practices at Whittington Hospital, UK, 2015; personal correspon- dence). Aim To improve current transfusion practice in transfusion-dependent thalassaemia patients at a tertiary haemoglobinopathy centre, by determining whether transition off TWRC, increasing transfusion rates, reducing the use of frusemide and creating uniform practice across patients is possible. Materials and Methods A review was undertaken of all 54 haemoglobinopathypatients (all but one, who is a transfusion dependent sickle cell anaemia patient, had thalassaemia) in our unit who received regular transfusions. The following factors were reviewed: i) blood products used; ii) weight-based transfusion rates; iii) post-transfusion use of frusemide; iv) presence of cardiac impairment (based on LV function and T2* cardiac MRI score) and transfusion reactions. Those patients with a history of cardiac impairment and transfusion reactions were excluded from the trial. The remaining patients (n=50) underwent the following: i) patients who were receiving triple-washed packed cells (TWPC) were transitioned to leucodepleted red blood cells (LDRC) over the year 2009; ii) cessation of frusemide use - this was carried out over a period of one month in 2015 to ensure all patients ceased use and to remove this confounder from any transfusion adverse effects in the future. Adverse events were recorded on the elec- tronic medical record; iii) increasing each patient’s transfusion rate of LDRC to 5 mL/kg/h up to a maximum of 300 mL/h over the following year 2015-2016; iv) each patient received a medical review at com- pletion of transfusion to ensure the increased rate was tolerated. Adverse reac- tions were to be documented in the elec- tronic medical record. Thalassemia Reports 2017; volume 7:6821 Correspondence: Chathupa Wickremaarachchi, Prince of Wales Hospital, Randwick, NSW, 2031, Australia. E-mail: chathuw@hotmail.com Key words: Thalassemia; transfusion medi- cine. Acknowledgments: the authors would like to thank the patients, volunteers, and colleagues at the hospital and laboratory for their support and assistance, in particular Kristen Brown, Gemma Carroll, Kirsten Scott and Phil Mondy. Conflicts of interest: the authors do not have any conflicts of interest to disclose. Received for publication: 28 May 2017. Revision received: 29 August 2017. Accepted for publication: 4 September 2017. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright C. Wickremaarachchi et al., 2017 Licensee PAGEPress, Italy Thalassemia Reports 2017; 7:6821 doi:10.4081/thal.2017.6821 Non commercial use only