3.6 Red blood cell transfusion in chronically transfused patients

3.6.2 Myelodysplasia

Evidence Statements for Fibrinogen and cryoprecipitate
Evidence Statements –
fibrinogen and cryoprecipitate
Evidence Consistency Clinical impact Generalisability Applicability
ES6.3 In patients with myelodysplasia, no studies were found reporting the effect of the pretransfusion Hb threshold on mortality, transfusion incidence, transfusion volume, thromboembolic events and functional or performance status NA NA NA NA NA

ES, evidence statement; NA, not applicable (see Table 2.1)

Practice Point – Myelodysplasia
PP24 In patients with myelodysplasia who are regularly and chronically transfused, there is no evidence to guide particular Hb thresholds. Decisions around appropriate triggers and frequency of transfusion need to be individualised, taking into account anaemia- related symptoms, functional or performance status, and the patient’s response to previous transfusions.

Hb, haemoglobin; PP, practice point

MDS refers to a group of bone marrow stem cell disorders that involve ineffective production (dysplasia) of the myeloid series. Patients with MDS develop one or more cytopenias due to progressive marrow failure. Although MDS may progress to acute leukaemia, a significant proportion of morbidity and mortality relate to the cytopenias. MDS predominantly occurs in older patients.

Anaemia is common in MDS, and supportive treatment with RBC transfusion has traditionally been prescribed. The main aim of RBC transfusion is to prevent or treat complications such as cardiovascular and cerebrovascular compromise. It is also used to improve the quality of life in MDS patients who have significant symptoms of malaise and fatigue. However, these symptoms may or may not be related to the anaemia, and assessment of the clinical response to the transfusion is therefore important.

The systematic review aimed to identify studies in patients with MDS, to determine at what Hb threshold transfusion should be given to avoid adverse complications. These include morbidity, mortality, and reduced functional or performance status. No studies were identified that assessed an association between pretransfusion Hb concentrations and mortality, functional or performance status, arterial thromboembolic events or RBC transfusion incidence or volume. Eighteen cohort studies were identified that assessed Hb and outcomes in MDS patients. However, none provided analysis related to pretransfusion Hb concentration; rather, they mainly aimed to assess the impact of Hb concentration at diagnosis. Most of the studies found that Hb concentration at diagnosis was a significant predictor of survival; a fact that is well recognised. Only one study reported that Hb concentration may also show a correlation with the results of functional or performance status testing in MDS patients.155

Thus, there is no evidence to guide clinicians on the Hb threshold for transfusion in patients with MDS and chronic anaemia. Further studies are needed to assess the benefit of transfusion in this population. Details on the use of ESAs in this patient group can be found in Section 3.3.6. Decisions about the need for and the frequency of transfusion require a risk–benefit assessment in each patient, taking into account their functional or performance status and Hb concentration.