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Thresholds for Blood Transfusions for MDS

Panelists: Rami Komrokji, MD, H. Lee Moffitt Cancer Center and Research Institute; Ellen K. Ritchie, MD, Weill Cornell Medicine; Mikkael Sekeres, MD, MS, Cleveland Clinic; Jamile M. Shammo, MD, Rush University Medical Center
Published: Friday, Feb 21, 2020



Transcript:

Mikkael Sekeres, MD, MS: Maybe we can switch gears a little bit and talk about patients who come in to see us, often they’re referred to us because they have cytopenias. What are your thresholds, Jamile, for blood product transfusions for patients?

Jamile M. Shammo, MD: There are institutional guidelines, and anybody who has a hemoglobin below 7 g/dL will receive a transfusion. Though, again, having a cutoff for older individuals or even younger that may be frequently transfusion-dependent probably will vary. I base it outside of that. On symptomatic anemias, I have younger individuals that tolerate hemoglobin at 6 g/dL, and so they may not get a transfusion unless it’s below that and some older individuals who are symptomatic at hemoglobin of 8 g/dL, so that would be where they would get it.

Mikkael Sekeres, MD, MS: Your institutional threshold, even for outpatients, is a hemoglobin of 7 g/dL?

Jamile M. Shammo, MD: Yes.

Mikkael Sekeres, MD, MS: What about for platelets?

Jamile M. Shammo, MD: It is around 10 g/dL or 15 g/dL if febrile. Anything below 10 g/dL, they will get an automatic transfusion, and if they have a fever, then it’s 15 g/dL. Of course, if they’re bleeding, they’ll get transfused irrespective of the platelet count.

Ellen K. Ritchie, MD: Right.

Mikkael Sekeres, MD, MS: How generous.

Jamile M. Shammo, MD: Yes.

Mikkael Sekeres, MD, MS: What about at your institution, what’s the threshold for outpatient…?

Rami Komrokji, MD: Similar. If patients are asymptomatic and don’t have comorbidities, we could go down to like a hemoglobin of 7 g/dL. Many of those patients, as you alluded earlier, are older so they have comorbidities. They really feel the difference when they are below 8 g/dL. Most of the patients I would say practically the threshold had been 8 g/dL to transfuse. There is a push sometimes to try to do the 1 unit transfusion nowadays rather than 2 units.

For me, it becomes just a matter of frequency and for some of those patients with MDS [myelodysplastic syndrome], sometimes if you give them 2 units, you give them a break of coming to the clinic the next week again. So, I try to push for 2-units transfusion in those patients. Platelets are similar, anything below 10 g/dL. It’s a very similar pattern, but I think that the hemoglobin is very variable between patients. I learn to ask patients, and sometimes it’s important to ask the patients how much better they feel after blood. Some patients will tell you they feel amazing, and some patients say it doesn’t make any difference for them. Then I’ll say that there is no point of us to just keep chasing numbers.

Mikkael Sekeres, MD, MS: Just to keep track, Jamile says 7 g/dL for hemoglobin gets a transfusion as an outpatient. Rami says 8 g/dL, for the most part. What about you, Ellen?

Ellen K. Ritchie, MD: You’re always faced with institutional pressures, and you’re faced with a patient that’s right in front of you. Institutionally they would prefer I not transfuse anyone who has a hemoglobin under 7 g/dL, or anyone who has platelets over 10 g/dL. They prefer that I give 1 unit. But the patient in front of you, often it’s very different. Those patients with cardiac disease or pulmonary disease, they cannot have any quality of life with a hemoglobin that is below 8 g/dL. Those patients I will transfuse, and I will fight the institution on that particular number.

Similarly, if I know a patient is transfusion-dependent, they come to me on a Thursday with a platelet count of 12 g/dL, and I’m not going to see them again until next week, I’m going to transfuse that patient. This is because I don’t think that they’re going to be able to make it to the next appointment. I agree with you  that it’s so much nicer in a patient who you know is transfusion- dependent, to be able to give them 2 units to give them a break from having to come to see you the next week. But you’re always working with the institutional pressures to try to do the best thing for your patient.

Mikkael Sekeres, MD, MS: It’s interesting. At our institution, it’s 8 g/dL, as an outpatient. The reason is that the study showing that patients could be transfused at a hemoglobin of 7 g/dL were conducted in the intensive care unit where people weren’t up and moving around and having to care for a spouse who’s also sick. We tend to be a little bit more aggressive as an outpatient and transfuse at 8 g/dL. We do give 1 unit of blood and that comes from the Choosing Wisely campaign from the ABIM [American Board of Internal Medicine]. It’s actually a wonderful campaign to call out some of the practices that we do that don’t make a lot of sense. But, like you said, the Choosing Wisely campaign looking at blood transfusions, isn’t necessarily thinking of a person with MDS who has to fight the traffic to get in to Chicago, or Cleveland, or New York, or Tampa to come and get a transfusion and would appreciate an actual week or 2 break from having to brave that traffic, valet park, check in, get a blood draw and wait to see us.

Ellen K. Ritchie, MD: And spend all day. Let’s not belittle that, all day getting the transfusion. By the time you leave your house and you get there, you get your type, and the blood is available for you. There’s a chair for you to be transfused, you get transfused, and you’re finished. That can be the same as going to work for a long day. It’s really important to keep in mind what that commitment is for the patient.

Transcript Edited for Clarity

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Transcript:

Mikkael Sekeres, MD, MS: Maybe we can switch gears a little bit and talk about patients who come in to see us, often they’re referred to us because they have cytopenias. What are your thresholds, Jamile, for blood product transfusions for patients?

Jamile M. Shammo, MD: There are institutional guidelines, and anybody who has a hemoglobin below 7 g/dL will receive a transfusion. Though, again, having a cutoff for older individuals or even younger that may be frequently transfusion-dependent probably will vary. I base it outside of that. On symptomatic anemias, I have younger individuals that tolerate hemoglobin at 6 g/dL, and so they may not get a transfusion unless it’s below that and some older individuals who are symptomatic at hemoglobin of 8 g/dL, so that would be where they would get it.

Mikkael Sekeres, MD, MS: Your institutional threshold, even for outpatients, is a hemoglobin of 7 g/dL?

Jamile M. Shammo, MD: Yes.

Mikkael Sekeres, MD, MS: What about for platelets?

Jamile M. Shammo, MD: It is around 10 g/dL or 15 g/dL if febrile. Anything below 10 g/dL, they will get an automatic transfusion, and if they have a fever, then it’s 15 g/dL. Of course, if they’re bleeding, they’ll get transfused irrespective of the platelet count.

Ellen K. Ritchie, MD: Right.

Mikkael Sekeres, MD, MS: How generous.

Jamile M. Shammo, MD: Yes.

Mikkael Sekeres, MD, MS: What about at your institution, what’s the threshold for outpatient…?

Rami Komrokji, MD: Similar. If patients are asymptomatic and don’t have comorbidities, we could go down to like a hemoglobin of 7 g/dL. Many of those patients, as you alluded earlier, are older so they have comorbidities. They really feel the difference when they are below 8 g/dL. Most of the patients I would say practically the threshold had been 8 g/dL to transfuse. There is a push sometimes to try to do the 1 unit transfusion nowadays rather than 2 units.

For me, it becomes just a matter of frequency and for some of those patients with MDS [myelodysplastic syndrome], sometimes if you give them 2 units, you give them a break of coming to the clinic the next week again. So, I try to push for 2-units transfusion in those patients. Platelets are similar, anything below 10 g/dL. It’s a very similar pattern, but I think that the hemoglobin is very variable between patients. I learn to ask patients, and sometimes it’s important to ask the patients how much better they feel after blood. Some patients will tell you they feel amazing, and some patients say it doesn’t make any difference for them. Then I’ll say that there is no point of us to just keep chasing numbers.

Mikkael Sekeres, MD, MS: Just to keep track, Jamile says 7 g/dL for hemoglobin gets a transfusion as an outpatient. Rami says 8 g/dL, for the most part. What about you, Ellen?

Ellen K. Ritchie, MD: You’re always faced with institutional pressures, and you’re faced with a patient that’s right in front of you. Institutionally they would prefer I not transfuse anyone who has a hemoglobin under 7 g/dL, or anyone who has platelets over 10 g/dL. They prefer that I give 1 unit. But the patient in front of you, often it’s very different. Those patients with cardiac disease or pulmonary disease, they cannot have any quality of life with a hemoglobin that is below 8 g/dL. Those patients I will transfuse, and I will fight the institution on that particular number.

Similarly, if I know a patient is transfusion-dependent, they come to me on a Thursday with a platelet count of 12 g/dL, and I’m not going to see them again until next week, I’m going to transfuse that patient. This is because I don’t think that they’re going to be able to make it to the next appointment. I agree with you  that it’s so much nicer in a patient who you know is transfusion- dependent, to be able to give them 2 units to give them a break from having to come to see you the next week. But you’re always working with the institutional pressures to try to do the best thing for your patient.

Mikkael Sekeres, MD, MS: It’s interesting. At our institution, it’s 8 g/dL, as an outpatient. The reason is that the study showing that patients could be transfused at a hemoglobin of 7 g/dL were conducted in the intensive care unit where people weren’t up and moving around and having to care for a spouse who’s also sick. We tend to be a little bit more aggressive as an outpatient and transfuse at 8 g/dL. We do give 1 unit of blood and that comes from the Choosing Wisely campaign from the ABIM [American Board of Internal Medicine]. It’s actually a wonderful campaign to call out some of the practices that we do that don’t make a lot of sense. But, like you said, the Choosing Wisely campaign looking at blood transfusions, isn’t necessarily thinking of a person with MDS who has to fight the traffic to get in to Chicago, or Cleveland, or New York, or Tampa to come and get a transfusion and would appreciate an actual week or 2 break from having to brave that traffic, valet park, check in, get a blood draw and wait to see us.

Ellen K. Ritchie, MD: And spend all day. Let’s not belittle that, all day getting the transfusion. By the time you leave your house and you get there, you get your type, and the blood is available for you. There’s a chair for you to be transfused, you get transfused, and you’re finished. That can be the same as going to work for a long day. It’s really important to keep in mind what that commitment is for the patient.

Transcript Edited for Clarity
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