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Background: Circulating CD71 + red blood cells (RBCs) have been reported to play an immunomodulatory role in vivo, which may contribute to adverse donor-recipient sex-mismatched transfusion outcomes. However, it is not clear how CD71 + RBC quantity in red cell concentrates (RCCs) is affected by manufacturing methods and donor factors such as donor sex, donor age, pre-donation hemoglobin (Hb), venous Hb (Hb v ) levels, and donation frequency., Methods: We determined CD71 + RBCs and Hb levels in whole blood (WB) from healthy donors (42 male/38 female). Using small-scale red cell filtration (RCF) and whole blood filtration (WBF) methods, leukoreduced RCCs were processed from WB samples (n = 6) and the CD71 + RBCs were determined at days 1, 7, and 28. We examined uni- and multivariate associations among CD71 + RBCs, donor factors, and manufacturing method., Results: Male donors had a higher CD71 + RBC concentration than females (p < .001), especially male donors aged 17-50 years with 1 or 2 WB donations over the previous 12 months. Donors with a Hb v above 155 g/L had a higher CD71 + RBC concentration than an Hb v level below 140 g/L (p < .05). There was a positive correlation between pre-donation Hb and CD71 + RBC concentration (Pearson r = 0.41). WBF RCCs had a higher total number of CD71 + RBCs than RCF-produced RCCs on day 1 (p < .05)., Discussion: RCCs have variable numbers of CD71 + RBCs. This makes understanding the impact of donor factors and manufacturing methods on the immunomodulatory effect of CD71 + RBCs critical in exploring donor-recipient sex-mismatched transfusions., (© 2023 AABB.)

Background: Washing red blood cell (RBC) units prior to transfusion is indicated for certain patients. In the United States, units stored at 1°C-6°C or transported at 1°C-10°C are available for issue up to 24 h, if not used immediately. The washing procedure commonly utilizes room temperature saline resulting in units starting out above the allowed temperature range. This leads to wastage if units are issued and returned too quickly before having a chance to equilibrate in a transport cooler., Study Design and Methods: Here we performed an experimental study of washed RBC quality comparing "ideal" storage conditions in a blood bank refrigerator to a "real-world" simulation of unit transport, including holding in a transport cooler. Twelve RBC units were washed and allocated evenly into either condition., Results: Measurements at 0, 1, 3, 6, 12, and 24 h post-washing revealed that placement in a transport cooler was associated with higher unit temperature prior to 12 h (p = .013) with a maximum difference of 9.3°C. Despite this difference, several measures of unit quality including extracellular potassium, pH, lactate, and free hemoglobin were indistinguishable between conditions (p = .382, .224, .286, .691, respectively). We selected half of the tested units from our irradiated inventory and confirmed increased potassium leak (p < .001) and accumulation of free hemoglobin (p = .012) in irradiated units., Discussion: Washed units stored under approved transport conditions are acceptable to return to inventory up to 24 h after washing and we provide a prediction interval-based temperature threshold for rejecting these units, permitting reduced waste., (© 2022 AABB.)

Background: Red blood cells (RBC) may be out of temperature control only for 30 minutes before they must be discarded, but evidence for this rule is weak. We investigated the effect on RBC quality of multiple exposures to 30°C., Study Design and Methods: RBC units made after 24 hours of whole blood ambient hold were pooled and split into adult and pediatric units and exposed to permitted deviations (5-hr core temperature 10°C, 12-hr surface temperature 10°C). Test units were exposed to 30°C once, twice, or three times on each of Days 15, 17, and 21, for 30 or 60 minutes. Negative controls were not exposed to 30°C; positive control was exposed to 30°C for 24 hours., Results: Adult units exposed once for 30 or 60 minutes (×3 occasions) showed no more hemolysis than negative control. Units exposed to 30°C for two or three periods of 60 minutes showed more hemolysis from Day 28. Hemolysis in pediatric units exposed for 30 minutes (×3) was not increased but units exposed to one or two periods of 60 minutes (×3) showed higher hemolysis. No differences were seen in supernatant potassium. ATP remained at an acceptable level on Day 28 in all but positive controls., Conclusions: There was no evidence of significant damage to RBC after exposure to 30°C for three periods of 30 minutes. Multiple exposures of 60 minutes caused limited damage but this was within current regulatory limits if there were three or fewer exposures, suggesting that a 60-minute rule may be feasible., (© 2012 American Association of Blood Banks.)

Acetylation of erythrocytic membranes by aspirin has not been reported. When erythrocytes or erythrocytic membranes are incubated with [acetyl-14C]aspirin, there is good evidence of very tight binding to membrane peptides in concentrations known to occur in vivo, 20 to 200 microM. No such evidence is observed with [carboxy-14C] aspirin. This indicates acetylation of membrane peptides. Although pronounced selectivity is not observed among the different peptides by gel filtration on Bio-Gel A-5M and sodium dodecyl sulfate polyacrylamide gel electrophoresis, there is overall saturation with a half-maximum at about 10 mM. The clinical significance of acetylation of membrane peptides of erythrocytes is unclear.

Background: Leading digit bias is a heuristic whereby humans overemphasize the left‐most digit when evaluating numbers (e.g., 9.99 vs. 10.00). The bias might affect the interpretation of hemoglobin results and influence red cell transfusion in hospitalized patients. Study Design and Methods: Adults who received a red cell transfusion while registered at the University Health Network (Toronto, Canada) between January 1, 2016 and January 1, 2022 (n = 6 years) were included. The primary analysis excluded apheresis, red cell disorders, radiology suites, and operating rooms. The primary comparison was a regression discontinuity analysis of transfusion occurrence above and below the hemoglobin threshold of 79 g/L (local units). Additional analyses tested other leading digit and control thresholds (71, 81, and 91 g/L). Secondary analyses explored temporal covariates and clinical subgroups. Results: A total of 211,872 red cell transfusions were identified over the study period (median pre‐transfusion hemoglobin 76 g/L; interquartile range = 69–92 g/L), with 107,790 inpatient transfusions in the primary analysis. The 79 g/L threshold showed 815 fewer red cell units above the threshold (95% confidence interval [CI]: −1215 to −415). The 69 g/L threshold showed 2813 fewer transfused units (95% CI: −4407 to −1220), and 89 g/L showed 40 fewer units (95% CI: −408 to 328). The effect was accentuated during daytime, weekday, and May–June months, persisted in analyses including all transfusions, and was absent at control thresholds. Conclusion: Leading digit bias might have a modest influence on the decision to transfuse red cells. The findings may inform practice guidelines and quasi‐experimental study design in transfusion research. [ABSTRACT FROM AUTHOR]

Background: Red blood cell exchange is often used prophylactically in patients with sickle cell disease, with the goal to maintain hemoglobin S (HbS) below a target threshold level. We reviewed whether the daily "rate of rise" (RoR) in HbS that occurs between procedures can be used for patient management. For some patients not achieving their HbS goals despite efficient exchanges, the post‐procedure hematocrit (Hct) target is increased to potentially suppress HbS production. This case series explores the utility of this approach, other clinical uses of the daily RoR in HbS, and the factors that influence it. Study Design and Methods: A total of 660 procedures from 24 patients undergoing prophylactic RBC depletion/exchange procedures were included. Laboratory values and clinical parameters were collected and used to calculate the daily RoR in HbS. Factors such as Hct or medications that might influence the RoR in HbS were evaluated. Results: The RoR in HbS varied widely between patients but remained relatively stable within individuals. Surprisingly, this value was not significantly influenced by changes in post‐procedure Hct or concurrent hydroxyurea use. A patient's average RoR in HbS effectively predicted the pre‐procedure HbS at the following visit (R2 = 0.65). Discussion: The RoR in HbS is a relatively consistent parameter for individual patients that is unaffected by medication use or procedural Hct targets and may be useful in determining intervals between procedures. [ABSTRACT FROM AUTHOR]

Background: Anemia in very low birth weight (VLBW) infants is common and frequently managed with red blood cell (RBC) transfusions. We utilized a linked vein‐to‐vein database to assess the role of blood donors and component factors on measures of RBC transfusion effectiveness in VLBW infants. Study Design and Methods: We linked blood donor and component manufacturing data with VLBW infants transfused RBCs between January 1, 2013 and December 31, 2016 in the Recipient Epidemiology Donor Evaluation Study‐III (REDS III) database. Using multivariable regression, hemoglobin increments and subsequent transfusion events following single‐unit RBC transfusion episodes were examined with consideration of donor, component, and recipient factors. Results: Data on VLBW infants (n = 254) who received one or more single‐unit RBC transfusions (n = 567 units) were linked to donor demographic and component manufacturing characteristics for analysis. Reduced post‐transfusion hemoglobin increments were associated with RBC units donated by female donors (−0.24 g/dL [95% confidence interval (CI) −0.57, −0.02]; p =.04) and donors <25 years old (−0.57 g/dL [95% CI −1.02, −0.11]; p =.02). For RBC units donated by male donors, reduced donor hemoglobin levels were associated with an increased need for subsequent recipient RBC transfusion (odds ratio 3.0 [95% CI 1.3, 6.7]; p <.01). In contrast, component characteristics, storage duration, and time from irradiation to transfusion were not associated with post‐transfusion hemoglobin increments. Conclusion: Donor sex, age, and hemoglobin levels were associated with measures of RBC transfusion effectiveness in VLBW infants. Mechanistic studies are needed to better understand the role of these potential donor factors on other clinical outcomes in VLBW infants. [ABSTRACT FROM AUTHOR]

Background: Robust evidence to inform best transfusion management after major oncologic surgery, where postoperative recovery might impact treatment regimens for cancer, is lacking. We conducted a study to validate the feasibility of a larger trial comparing liberal versus restrictive red blood cells (RBC) transfusion strategies after major oncologic surgery. Study Design and Methods: This was a two‐center, randomized, controlled, study of patients admitted to the intensive care unit after major oncologic surgery. Patients whose hemoglobin level dropped below 9.5 g/dL, were randomly assigned to immediately receive a 1‐unit RBC transfusion (liberal) or delayed until the hemoglobin level dropped below 7.5 g/dL (restrictive). The primary outcome was the median hemoglobin level between randomization to day 30 post‐surgery. Disability‐free survival was evaluated by the WHODAS 2.0 questionnaire. Results: 30 patients were randomized (15 patients/group) in 15 months with a mean recruitment rate of 1.8 patients per month. The median hemoglobin level was significantly higher in the liberal group than in the restrictive group: 10.1 g/dL (IQR 9.6–10.5) versus 8.8 g/dL (IQR 8.3–9.4), p <.001, and RBC transfusion rates were 100% versus 66.7%, p =.04. The disability‐free survival was similar between groups: 26.7% versus 20%, p = 1. Discussion: Our results support the feasibility of a phase 3 randomized controlled trial comparing the impact of liberal versus restrictive transfusion strategies on the functional recovery of critically ill patients following major oncologic surgery. [ABSTRACT FROM AUTHOR]

Background: Pathogen reduction technology (PRT) may improve the safety of RBCs for transfusion. As the Czech Republic considers PRT, we asked what effects riboflavin and UV light PRT pre‐freezing has on the post‐thaw recovery and properties of cryopreserved RBCs (CRBCs) after deglycerolization and liquid storage. Study Design and Methods: 24 Group O whole blood (WB) units were leukoreduced and then treated with riboflavin and UV light PRT (Mirasol, Terumo BCT, USA) before cryopreservation (T‐CRBC); 20 similarly‐collected units were untreated controls (C‐CRBC). Units were processed to RBCs and then cryopreserved with 40% glycerol (wt/vol), frozen at −80°C, stored >118 days, reconstituted as deglycerolized RBC units in AS‐3, and stored at 4 ± 2°C for 21 days. One treated unit sustained massive hemolysis during the post‐thaw wash process and was removed from data analysis. The remaining units were assessed pre‐PRT, post‐PRT, and post‐thaw‐wash on days 0, 7, 14, and 21 for hematocrit, volume, hemoglobin per transfusion unit, pH, % hemolysis, hemoglobin in the supernatant, potassium, phosphorus, NH3, osmolality, ATP, and 2,3‐diphosphoglycerate. Results: PRT with leukoreduction caused a 5% loss of RBC followed by a 24% freeze–thaw‐wash related loss for a total 28% loss but treated units contained an average of 45 g of hemoglobin, meeting European Union guidelines for CRBC. T‐CRBCs displayed higher post‐wash hemolysis, potassium, and ammonia concentrations, and lower ATP at the end of storage. Conclusions: Cryopreserved RBCs from Riboflavin and UV light‐treated WB meet the criteria for clinical use for 7 days after thawing and provide additional protection against infectious threats. [ABSTRACT FROM AUTHOR]

Background: Good models of chronic red blood cell (RBC) transfusion can improve care by accurately estimating time‐dependent hemoglobin (Hb) levels and clinically relevant transfusion parameters. Study Design and Methods: A previously derived mathematical model based on overall Hb mass balance (HMB model) with input parameters of transfused units, transfusion efficiency, RBC lifespan, endogenous Hb, and transfusion interval was applied to three separate clinical studies spanning six transfusion conditions across patient populations with myelodysplastic syndrome (MDS) or thalassemia. Results: The HMB model accurately predicted mean pretransfusion Hb levels for each ensemble cohort of patients with thalassemia or MDS. Dynamic changes in Hb levels were modeled as a function of changes in key input parameters. Improving the 24‐h post‐transfusion RBC survival from 72% to 86% can be used to either (1) reduce RBC usage by 15%–20% through longer transfusion intervals or (2) increase pretransfusion [Hb] by 8%–11% while maintaining a constant transfusion interval. Discussion: The endogenous Hb level is introduced in the HMB model which represents the patient's self‐contribution to overall Hb levels via the autologous RBC lifecycle and was estimated to be 5.0 g/dL for patients with MDS or thalassemia. Transfusion therapy approaches and complementary therapeutics can target multiple, unique model inputs while monitoring net, overall impact on transfusion efficacy. Applying the HMB model to fit individual patient Hb fluctuations will be explored in the future. [ABSTRACT FROM AUTHOR]

BackgroundRecent publications have reported conflicting results regarding the role of blood donor tobacco use on hemoglobin (Hb) levels in patients after red blood cell (RBC) transfusion. We examined associations and interactions between donor, component, and recipient factors to better understand the impact of donor smoking on transfusion outcomes.Study design and methodsWe linked blood donor and component manufacturing data, including self-reported cigarette smoking, with a cohort of patients transfused RBCs between 2013 and 2016. Using multivariable regression, we examined Hb increments and subsequent transfusion requirements after single-unit RBC transfusion episodes, adjusting for donor, component, and recipient factors.ResultsWe linked data on 4038 transfusion recipients who received one or more single-unit RBC transfusions (n = 5086 units) to donor demographic and component manufacturing characteristics. Among RBC units from smokers (n = 326), Hb increments were reduced after transfusion of gamma-irradiated units (0.76 g/dL; p = 0.033) but not unirradiated units (1.04 g/dL; p = 0.54) compared to those from nonsmokers (1.01 g/dL; n = 4760). In parallel with changes in Hb levels, donor smoking was associated with the receipt of additional RBC transfusions for irradiated (odds ratio [OR], 2.49; p = 0.01) but not unirradiated RBC units (OR, 1.10; p = 0.52).ConclusionDonor smoking was associated with reduced Hb increments and the need for additional transfusions in recipients of gamma-irradiated RBC units. Additional research is needed to better understand interactions between donor, component, and recipient factors on efficacy measures of RBC transfusion.

Background: Circulating CD71+ red blood cells (RBCs) have been reported to play an immunomodulatory role in vivo, which may contribute to adverse donor–recipient sex‐mismatched transfusion outcomes. However, it is not clear how CD71+ RBC quantity in red cell concentrates (RCCs) is affected by manufacturing methods and donor factors such as donor sex, donor age, pre‐donation hemoglobin (Hb), venous Hb (Hbv) levels, and donation frequency. Methods: We determined CD71+ RBCs and Hb levels in whole blood (WB) from healthy donors (42 male/38 female). Using small‐scale red cell filtration (RCF) and whole blood filtration (WBF) methods, leukoreduced RCCs were processed from WB samples (n = 6) and the CD71+ RBCs were determined at days 1, 7, and 28. We examined uni‐ and multivariate associations among CD71+ RBCs, donor factors, and manufacturing method. Results: Male donors had a higher CD71+ RBC concentration than females (p <.001), especially male donors aged 17–50 years with 1 or 2 WB donations over the previous 12 months. Donors with a Hbv above 155 g/L had a higher CD71+ RBC concentration than an Hbv level below 140 g/L (p <.05). There was a positive correlation between pre‐donation Hb and CD71+ RBC concentration (Pearson r = 0.41). WBF RCCs had a higher total number of CD71+ RBCs than RCF‐produced RCCs on day 1 (p <.05). Discussion: RCCs have variable numbers of CD71+ RBCs. This makes understanding the impact of donor factors and manufacturing methods on the immunomodulatory effect of CD71+ RBCs critical in exploring donor–recipient sex‐mismatched transfusions. [ABSTRACT FROM AUTHOR]

Background: Differences in manufacturing conditions using the Haemonetics ACP 215 cell processor result in cryopreserved red cell concentrates (RCCs) of varying quality. This work studied the effect of processing method, additive solution, and storage duration on RCC quality to identify an optimal protocol for the manufacture of cryopreserved RCCs. Materials and methods RCCs were pooled‐and‐split and stored for 7, 14, or 21 days before cryopreservation. Units were glycerolized with the ACP 215 using a single or double centrifugation method. After thawing, the RCCs were deglycerolized, suspended in AS‐3, SAGM, ESOL, or SOLX/AS‐7, and stored for 0, 3, 7, 14, or 21 days before quality testing. Quality assessments included hemoglobin content, hematocrit, hemolysis, adenosine triphosphate (ATP), supernatant potassium, and mean cell volume. Results: Both glycerolization methods produced RCCs that met regulatory standards for blood quality. Dual centrifugation resulted in higher hemoglobin content, fewer processing alerts, and a shorter deglycerolization time than single centrifugation processing. Units processed with AS‐3 and ESOL met regulatory standards when stored for up to 21 days pre‐cryopreservation and 21 days post‐deglycerolization. However, ESOL demonstrated superior maintenance of ATP over RBCs in AS‐3. Some RCCs suspended in SAGM and SOLX exceeded acceptable hemolysis values after 7 days of post‐deglycerolization storage regardless of pre‐processing storage length. Conclusions: When manufacturing cryopreserved RCCs using the ACP 215, dual centrifugation processing with AS‐3 or ESOL additive solutions is preferred, with storage periods of up to 21 days both pre‐processing and post‐deglycerolization. [ABSTRACT FROM AUTHOR]

Background: Hemolysis releases toxic cell‐free hemoglobin (Hb), heme, and iron, which overwhelm their natural scavenging mechanisms during acute or chronic hemolytic conditions. This study describes a novel strategy to purify a protein cocktail containing a comprehensive set of scavenger proteins for potential treatment of hemolysis byproducts. Study Design and Methods: Tangential flow filtration was used to purify a protein cocktail from Human Cohn Fraction IV (FIV). A series of in vitro assays were performed to characterize composition and biocompatibility. The in vivo potential for hemolysis byproduct mitigation was assessed in a hamster exchange transfusion model using mechanically hemolyzed blood plasma mixed with the protein cocktail or a control colloid (dextran 70 kDa). Results: A basis of 500 g of FIV yielded 62 ± 9 g of a protein mixture at 170 g/L, which bound to approximately 0.6 mM Hb, 1.2 mM heme, and 1.2 mM iron. This protein cocktail was shown to be biocompatible in vitro with red blood cells and platelets and exhibits nonlinear concentration dependence with respect to viscosity and colloidal osmotic pressure. In vivo assessment of the protein cocktail demonstrated higher iron transport to the liver and spleen and less to the kidney and heart with significantly reduced renal and cardiac inflammation markers and lower kidney and hepatic damage compared to a control colloid. Discussion Taken together, this study provides an effective method for large‐scale production of a protein cocktail suitable for comprehensive reduction of hemolysis‐induced toxicity. [ABSTRACT FROM AUTHOR]

When investigating the effect voxelotor treatment might have on future HPLC hemoglobin fractionations, we learned about potential issues associated with voxelotor interference on HPLC hemoglobin fractionation assays, as described above. After confirming the presence of unresolved peaks in the patient sample that were characteristic of voxelotor interference, we implemented an approach (Figure 1) to mitigate the effect of the interference that is similar to a previously published approach.1 GLO:1YB/01jun21:trf16405-fig-0001.jpg PHOTO (COLOR): 1 Hemoglobin fractionation for patient taking voxelotor workflow gl When a quantitative hemoglobin fractionation is requested, an automated order inquiry now asks the provider if the patient is taking voxelotor. Voxelotor prescribing information describes that voxelotor may interfere with high-performance liquid chromatography (HPLC) and recommends performance of hemoglobin quantitation using HPLC when patients are not taking the drug "[i]f precise quantitation of Hb species is required."3 Published studies have demonstrated voxelotor interference in hemoglobin fractionation assays due to the formation of voxelotor-hemoglobin complexes.1,2 The voxelotor-hemoglobin complexes cause resolved or unresolved interfering peaks in capillary electrophoresis and HPLC measurement procedures. [Extracted from the article]

Background: Though weight is a major consideration when transfusing blood in pediatric patients, it is generally not considered when dosing transfusions in adults. We hypothesized that the change in hemoglobin (Hb) concentration is inversely proportional to body weight when transfusing red blood cells (RBC) in adults.Methods: A total of 13,620 adult surgical patients at our institution were assessed in this retrospective cohort study (2009-2016). Patients were stratified based on total body weight (kg): 40-59.9 (16.6%), 60-79.9 (40.4%), 80-99.9 (28.8%), 100-119.9 (11.3%), and 120-139.9 (2.9%). The primary outcome was the change in Hb per RBC unit transfused. Subgroup analyses were performed after stratification by sex (male/female) and the total number of RBC units received (1/2/≥3 units). Multivariable models were used to assess the association between weight and change in Hb.Results: As patients' body weight increased, there was a decrease in the mean change in Hb per RBC unit transfused (40-59.9 kg: 0.85 g/dL, 60-79.9 kg: 0.73 g/dL, 80-99.9 kg: 0.66 g/dL, 100-119.9 kg: 0.60 g/dL, 120-139.9 kg: 0.55 g/dL; p < .0001). This corresponded with a 35% difference in the change in Hb between the lowest and highest weight categories on univariate analysis. Similar trends were seen after subgroup stratification. On multivariable analysis, for every 20 kg increase in patient weight, there was a ~6.5% decrease in the change in Hb per RBC unit transfused (p < .0001).Conclusions: Patient body weight differentially impacts the change in Hb after RBC transfusion. These findings justify incorporating body weight into the clinical decision-making process when transfusing blood in adult surgical patients. [ABSTRACT FROM AUTHOR]

Background: A patientʼs hemoglobin is typically expected to rise by 1 g/dL/unit transfused PRBCs. However, it has been theorized that mechanisms such as hyperbilirubinemia and splenomegaly might lead to either a direct lysis or sequestration of red blood cells that could decrease this proportionate response. Study Design and Methods: Patients with resolved GI bleeding but still requiring transfusion to correct anemia were compared in cirrhosis and control groups. A retrospective chart review between 2015 and 2020 was conducted at a single institution. Data collected included age, sex, BMI, GI bleed diagnosis, number of PRBCs transfused, presence of splenomegaly and spleen size, alcohol use history, type of cirrhosis, MELD‐Na at admission, GFR, and pre‐and post‐transfusion labs: total bilirubin, ALT, hemoglobin, hematocrit. A logic regression was performed for each group looking at which factors were associated with a successful response (defined as >0.9 g/dL hemoglobin per unit transfused). Results: Mean change in hemoglobin was 0.77 g/dL in patients with cirrhosis compared to 1.46 g/dL in patients without (P <.001, N = 103). Odds ratios for presence of splenomegaly (0.22, N = 78) and female sex (4.39, N = 102) in predicting adequate response (>0.9 g/dL/unit) were both significant (P =.002) as well as portal hypertensive bleed diagnosis (0.28, N = 85, P =.0015). Factors that did not contribute included: age, race, BMI, alcohol use, GFR, change in ALT, and change in total bilirubin. Conclusions: Patients with cirrhosis have an approximately 50% decreased response to transfusion with PRBCs after resolution of a gastrointestinal bleed in comparison to patients without cirrhosis. Risk factors included splenomegaly, portal hypertension, and male sex. [ABSTRACT FROM AUTHOR]

Background: Hemoglobin (Hb)‐based oxygen (O2) carriers (HBOCs) are being developed as alternatives to red blood cells and blood when these products are unavailable. Clinical trials of previous HBOC generations revealed side effects, including hypertension and vasoconstriction, that were not observed in preclinical studies. Large molecular weight (MW) polymerized bovine Hb (PolybHb) represents a new class of HBOC with promising results. We evaluated the safety profile of PolybHb after an exchange transfusion (ET) in guinea pigs (GPs). This study compares changes in indices of cardiac, inflammatory, and organ function after ET with high (R‐state) and low (T‐state) O2 affinity PolybHb with high MW. Study Design and Methods: Guinea pigs underwent a 20% ET with PolybHb. To assess the implication of PolybHb ET on the microcirculation, hamsters instrumented with a dorsal window chamber were subjected to a similar volume ET. Results: T and R‐state PolybHb did not induce significant alterations in cardiac function. T‐state PolybHb induced mild vasoconstriction shortly after transfusion, while R‐state did not have acute effects on microvascular tone. Conclusion: Large MW PolybHbs were found to be safe and efficacious in increasing O2 carrying capacity and the O2 affinity of the PolybHb did not affect O2 delivery or extraction by tissues in relevant preclinical models. In conclusion, these results suggest that both T‐state and R‐state PolybHb are safe and do not impair O2 delivery. The results are encouraging and support further evaluation of high MW PolybHbs and their future feasibility compared to allogenic blood in a trauma model. [ABSTRACT FROM AUTHOR]

Background: Red blood cell (RBC) transfusion is common in surgical patients, yet optimal transfusion targets are incompletely defined in the perioperative period. Hemoglobin levels at the time of hospital discharge may provide insight into transfusion practices, anemia management, and patient outcomes. Study Design and Methods: This is an observational cohort study of adults receiving RBC transfusion during noncardiac surgery from 2010 to 2014. Multivariable regression was used to assess the relationships between hospital discharge hemoglobin concentrations, anemia severity (severe: <8 g/dL; moderate: 8‐10 g/dL; mild/none: ≥10 g/dL), and clinical outcomes, including a primary outcome of 30‐day hospital readmission and secondary outcomes of posthospitalization RBC transfusion, composite stroke or myocardial infarction, and mortality. Results: A total of 3129 patients were included: 165 (5%) with severe discharge anemia, 1962 (63%) moderate, and 1002 (32%) with mild/none. Five hundred ninety‐two (19%) were readmitted, with the highest rates observed with severe anemia (26% vs 19% for mild/none). Readmissions were not significantly different after multivariable adjustment (overall P =.216); however, in those receiving postoperative intensive care, severe anemia was associated with increased readmission rates (hazard ratio [HR], 1.72; 95% confidence interval [CI], 1.09‐2.71; reference mild/none]. Posthospitalization RBC transfusion rates were highest with severe anemia (25% vs 10% for mild/none; adjusted HR, 2.2; 95% CI, 1.5‐3.3; P <.001). There were no significant differences in composite stroke/myocardial infarction, or mortality. RBC transfusion volumes did not modify anemia‐outcome relationships. Conclusion: Hospital discharge hemoglobin values for transfused surgical patients were not associated with hospital readmission rates except for those receiving postoperative intensive care. Further evaluation is warranted to understand downstream consequences of postsurgical anemia. See editorial on page 2168–2170, in this issue [ABSTRACT FROM AUTHOR]

Backgrounds: Intravenous transfusion sometimes encounters difficulty under prehospital conditions when peripheral vessels are collapsed and inaccessible. We investigated whether the cellular type hemoglobin-based oxygen carriers (Hemoglobin Vesicles: HbVs) allow intraosseous administration into blood circulation for the resuscitation of rabbits with severe hemorrhagic shock.Study Design and Methods: New Zealand white rabbits (2.5 kg average) were set in severe hemorrhagic shock [mean arterial pressure (MAP): 21 ± 2 mm Hg, Hb 5.1 ± 0.8 g/dL]. Immediately thereafter, 12 mL/kg of HbVs, 5% human serum albumin (HSA), autologous whole blood (WB), stored red blood cells (RBCs) or 36 mL/kg of Lactated Ringer's (LR) were intraosseously transfused, followed by an additional intraosseous transfusion with 8 mL/kg of HSA (following HbV, HSA or stored RBC transfusion), or WB or 24 mL/kg of LR (following LR transfusion), respectively.Results: Intraosseous transfusion of HbVs increased MAP (48 ± 9 mm Hg) and improved hypohemoglobinemia (7.1 ± 0.6 g/dL) as well as WB or RBC transfusion. In contrast, neither HSA nor LR improved hemodynamics or Hb levels. Seven out of 10 rabbits receiving HbVs survived for 24 hours, while only one out of 10 rabbits receiving LR survived (WB and RBC; 100% survivals, HSA; 30% survival).Conclusions: Intraosseous infusion of HbVs might be an effective initial treatment to maintain hemodynamics during acute hemorrhagic shock. This approach could be used in emergency situations in which access to peripheral vessels is difficult. [ABSTRACT FROM AUTHOR]

Background: This study evaluated blood components processed by the platelet rich plasma (PRP) method from fresh whole blood (FWB) treated with a pathogen reduction technology (PRT). The effects of storage temperature on PRT treated platelet concentrates (PCs) were also examined.Study Design and Methods: PRT was performed using riboflavin and ultraviolet light on FWB in citrate phosphate dextrose anticoagulant. Following PRT, red blood cells (RBCs), PCs, and plasma for fresh frozen plasma (FFP), were isolated by sequential centrifugation. RBCs were stored at 4°C, FFP at -80°C, and PC at 22°C or at 4°C. Components were assayed throughout their storage times for blood gases, chemistry and CBC, hemostatic function as well as platelet (PLT) and RBC integrity.Results: Component processing following PRT resulted in a significant drop in platelet recovery. Most PRT-PC bags fell below AABB guidelines for platelet count. PRT-PC also showed a decrease in clot strength and decreased aggregometry response. Platelet caspases were activated by PRT. Storage at 4°C improved platelet function. In PRT-FFP, prothrombin time and partial thromboplastin time (PT and aPTT) were prolonged; factors V, VII, VIII, and XI, protein C, and fibrinogen were significantly decreased. Free hemoglobin was elevated two-fold in PRT-RBC.Conclusion: Blood components isolated by the PRP method from PRT-treated WB result in a high percentage of PC that fail to meet AABB guidelines. FFP also shows diminished coagulation capacity. However, PRT-RBC are comparable to control-RBC. PRT-WB retains acceptable hemostatic function but alternatives to the PRP method of component separation may be more suitable. [ABSTRACT FROM AUTHOR]

Background: Pediatric patients with sepsis in intensive care units are at high risk of developing anemia, which might have adverse effects on their prognosis. This study aimed to evaluate the impact of red blood cell (RBC) transfusion on the outcomes of patients admitted to a pediatric intensive care unit (PICU) with sepsis.Methods: We conducted a prospective randomized clinical trial, enrolling 67 children, aged 2 to 144 months who were admitted to a PICU with a new episode of sepsis from November 2017 to April 2018. Patients were allocated randomly to two groups: Group 1, liberal transfusion strategy group, including 33 patients who had initial hemoglobin (Hb) between 7 or greater and less than 10 g/dL and received an RBC top-up transfusion to 12 g/dL; and Group 2, restrictive strategy group, including 34 patients who had the same Hb range and did not receive RBCs. Patients with Hb less than 7 or greater than 10 g/dL were excluded.Results: Of 33 patients who received liberal transfusions, 31 (93.94%) required ventilation, and 29 (87.88%) had multiorgan dysfunction. They had a significantly lengthier hospital stay and a higher incidence of acute respiratory distress syndrome and acute lung injury. Moreover, mortality was significantly higher in the liberal transfusion group (42.4% vs. 17.6%).Conclusions: Compared to the restrictive transfusion strategy, liberal transfusion might be associated with a worse outcome. However, the possible role of other known and unknown confounding factors and minor protocol violations should be taken into consideration. We recommend minimizing factors worsening anemia in PICU patients to reduce the need for transfusion. [ABSTRACT FROM AUTHOR]

Background: During sepsis, higher plasma cell-free hemoglobin (CFH) levels portend worse outcomes. In sepsis models, plasma proteins that bind CFH improve survival. In our canine antibiotic-treated Staphylococcus aureus pneumonia model, with and without red blood cell (RBC) exchange transfusion, commercial human haptoglobin (Hp) concentrates bound and compartmentalized CFH intravascularly, increased CFH clearance, and lowered iron levels, improving shock, lung injury, and survival. We now investigate in our model how very high CFH levels and treatment time affect Hp's beneficial effects.Materials and Methods: Two separate canine pneumonia sepsis Hp studies were undertaken: one with exchange transfusion of RBCs after prolonged storage to raise CFH to very high levels and another with rapidly lethal sepsis alone to shorten time to treat. All animals received continuous standard intensive care unit supportive care for 96 hours.Results: Older RBCs markedly elevated plasma CFH levels and, when combined with Hp therapy, created supraphysiologic CFH-Hp complexes that did not increase CFH or iron clearance or improve lung injury and survival. In a rapidly lethal bacterial challenge model without RBC transfusion, Hp binding did not increase clearance of complexes or iron or show benefits seen previously in the less lethal model.Discussion: High-level CFH-Hp complexes may impair clearance mechanisms and eliminate Hp's beneficial effect during sepsis. Rapidly lethal sepsis narrows the therapeutic window for CFH and iron clearance, also decreasing Hp's beneficial effects. In designing clinical trials, dosing and kinetics may be critical factors if Hp infusion is used to treat sepsis. [ABSTRACT FROM AUTHOR]

Background: The number of red blood cell units transfused per capita in China is lower than in western countries and the reason(s) for the difference is unknown.Study Design and Methods: We randomly chose 5050 transfused patients from five Chinese hospitals. We compared transfused cases to nontransfused controls matched for the same underlying diagnosis. We assessed the pretransfusion hemoglobin (Hb) trigger and other clinical characteristics associated with transfusion. After stratifying by underlying disease, we compared pretransfusion Hb level in Chinese hospitals to 12 US hospitals.Results: In 5050 patients who received transfusion, the pretransfusion Hb levels were lower in medical (6.3 g/dL) compared to surgical patients receiving transfusion postoperatively (8.1 g/dL). In patients with nonsurgical diagnoses, the pretransfusion Hb was much lower than that in the United States; the difference in mean Hb level varied by underlying diagnosis from 0.4 to 1.8 g/dL. In case-control analysis of cases (n = 1356) compared to controls (n = 1201), the pretransfusion Hb showed the strongest association with transfusion. Compared to 10 g/dL, the odds ratio (95% confidence interval) for pretransfusion Hb of 7 to 7.9 g/dL was 37.7 (24.8-57.4).Conclusion: Transfusion triggers in five Chinese hospitals appear comparable to those in the United States for surgical patients; however, medical patients have lower pretransfusion Hb levels (approx. 6 g/dL). Of the factors assessed, the pretransfusion Hb was most strongly associated with transfusion. The clinical impact of lower transfusion thresholds used in China is unknown. [ABSTRACT FROM AUTHOR]

Background: Patients with cancer or chronic hematologic disorders frequently receive red blood cell (RBC) transfusions. Based on long-standing assumptions, each RBC unit is thought to increase recipient hemoglobin by 1 g/dL, but smaller increments can occur. A better understanding of recipient factors affecting hemoglobin increments could help providers manage these patients.Methods: Data were collected as a part of the observational Red Cells in Outpatients Transfusion Outcomes (RETRO) study of outpatients with hematologic or cancer-related diagnoses. Hemoglobin was measured before transfusion and 30 minutes after transfusion. A classification and regression tree (CART) analysis was performed to identify statistically significant associations with clinical variables. A corresponding prediction equation was developed and validated using linear regression.Results: A total of 195 participants had both pre- and posttransfusion hemoglobin values for analysis. The median age was 66 years, and patients received one (73%) or two (27%) RBC units during the transfusion episode. The overall median change in hemoglobin was 0.6 g/dL per RBC unit. Both CART analysis and linear regression identified the following significant predictors of hemoglobin increment: number of units received (positive correlation), patient estimated circulating blood volume (negative correlation), pretransfusion hemoglobin (negative correlation), and patient age (negative correlation).Conclusion: In this study of outpatients with hematologic disease, most patients had a hemoglobin increment of less than 1 g/dL/unit. Recipient-specific factors influenced the hemoglobin increment at 30 minutes, and providers should consider circulating blood volume, pretransfusion hemoglobin, and recipient age, when developing patient-specific RBC transfusion plans for this unique cohort. [ABSTRACT FROM AUTHOR]

Background: Apheresis red blood cell (RBC) exchange (RCE) is a standard intervention for patients with sickle cell anemia (SCA) who have had previous thromboembolic stroke or intractable chronic pain. Replacing sickling cells with those containing hemoglobin A (HbA) minimizes microvascular pathophysiology that produces clinical crises. Limited data exist regarding the interval changes in HbA between transfusions. We sought to describe the HbA decrement between RCE procedures and its relationship to clinical status.Study Design and Methods: SCA patients (all hemoglobin SS disease) treated with maintenance RCE (n = 21) over a 15-month period at two neighboring institutions were retrospectively reviewed. Time-normalized daily HbA decrement was calculated to reflect loss of transfused RBCs, and annual events of either emergency department or hospital admissions for SCA complications were noted. Associations between HbA decrement and laboratory measures were calculated using mixed linear regression models and unpaired t test was used to compare HbA decrement between high and low event rate groups.Results: A total of 31 events were recorded, and mean HbA decrement per day was 0.77 ± 0.16%. The mean interval between RCEs was 36 ± 12 days. Patients with more annual events exhibited a significantly greater daily HbA decrement (p = 0.007). No significant association between RBC unit age and HbA decrement or annual event rate was observed.Conclusions: Patients exhibiting greater daily HbA decrement were more likely to have multiple emergency department visits or admissions for sickling crises. Modulating HbA decrement may merit study as an intermediate metric for interventions to improve outcomes in hemoglobin SS disease. [ABSTRACT FROM AUTHOR]

Background: American Association of Blood Banks (AABB) guidelines suggest that packed red blood cells (PRBCs) be administered through a dedicated intravenous (IV) catheter. Literature supporting this broad-scope declaration are scarce. Obtaining additional IV access is painful, costly, and an infectious risk. We evaluated the effect of co-incubating PRBCs with crystalloids and medications on PRBC hemolysis, membrane deformability, and aggregation, as well as medication concentration.Methods: PRBCs were co-incubated 5 minutes with plasma, normal saline (NS), 5% dextrose in water (D5W), Plasmalyte, epinephrine (epi), norepinephrine (norepi), dopamine (dopa), or Propofol (prop). Samples were then assessed for hemolysis (free hemoglobin, serum potassium), membrane deformability (elongation index [EI]), aggregation (smear, critical shear stress [mPa]) and drug concentration (High Performance Liquid Chromatography/Tandem Mass Spectrometry [LCMS-MS]). Significance (p ≤ 0.05) was determined by Wilcoxon-paired comparisons or Wilcoxon/Kruskall Willis with post-hoc Dunn's test.Results: Compared to co-incubation with plasma: 1) co-incubation resulted in significantly increased hemolysis only when D5W as used (free hemoglobin, increased potassium); 2) EI trended lower when co-incubated with D5W and trended toward higher when co-incubated with prop; 3) aggregation was significantly lower when PRBCs co-incubated with NS, D5W, or Plasmalyte, and trended lower when co-incubated with epi, norepi, or dopa. Medication concentrations were between those predicted by distribution only in plasma and distribution through the entire intra- and extracellular space.Conclusion: Our data suggest that 5 minutes of PRBC incubation with isotonic crystalloids or catecholamines does not deleteriously alter PRBC hemolysis, membrane deformability, or aggregation. Co-incubation with D5W likely increases hemolysis. Propofol may promote hemolysis. [ABSTRACT FROM AUTHOR]

Background: Blood bank inventories must balance adequate supply with minimal outdate rates. The day-to-day practice of ordering red blood cell (RBC) inventory usually involves manually comparing current inventory levels with predetermined thresholds calculated from historical usage and ordering the difference. To date, there have been no published methods for ordering RBC inventory based on laboratory characteristics of admitted patients.Study Design and Methods: We designed and implemented a blood ordering algorithm to provide a more accurate measure of predicted RBC utilization in our institution. Cerner Command Language (Cerner Millennium) was used to extract and combine historical RBC unit usage, current inventory levels, and system-wide hematology values and blood groups. This report contains a suggested order based on current inventory, historical inventory data, ABO group, and the current "anemia index" for the institution.Results: The mean daily total RBC inventory was significantly reduced after implementation (401.7 units vs. 309.0 units, p < 0.05). There was a significant reduction in monthly RBC outdates in this period (19.1 vs. 8.1, p < 0.05). The age of RBCs at time of transfusion was reduced as well.Conclusion: We developed a novel algorithm that automatically generates a suggested RBC inventory order using real-time hospital-wide survey of patient ABO typing, hematology values, and historical data. After implementation of the algorithm we demonstrated a significant reduction in daily inventory levels and RBC outdate rates. [ABSTRACT FROM AUTHOR]

Background: RBC concentrates are commonly stored for up to 42 days but there has been conflicting evidence on the effect of storage duration and clinical outcomes. Most clinical studies have focused on possible associations between duration of storage time and risk for adverse outcomes, including mortality. Recent clinical trials did not find any such associations, but fewer studies have addressed whether storage time affects component efficacy. The main aim of this study was to determine the effect of RBC storage time on hemoglobin increment in transfused patients.Study Design and Methods: Transfusion data on a cohort of patients with myelodysplastic syndromes were linked to hemoglobin measurements taken between 2 days before and 28 days after a transfusion episode. We applied a mixed-effect linear regression model, accounting for patient characteristics and time from transfusion to next hemoglobin measurement, to study the effect of RBC storage on the hemoglobin increment.Results: The study population consisted of 225 patients who received 6437 RBC units. Compared to units stored less than 5 days, transfusion of blood units stored 5 to 9, 10 to 19, 20 to 29, or 30 or more days resulted in hemoglobin increases that were 0.83 (95% confidence interval [CI], 0.24-1.41), 0.92 (95% CI, 0.34-1.51), 1.33 (95% CI, 0.65-2.02) and 1.51 (95% CI, 0.58-2.43) g/L lower, respectively, per RBC unit. Results were consistent in sensitivity analyses.Conclusions: Longer RBC storage was associated with a smaller increase in hemoglobin concentration after transfusion. Although statistically significant, the effect was modest, and its clinical relevance in subgroups of patients should be investigated in prospective clinical trials. [ABSTRACT FROM AUTHOR]

Background: Blood donors have an increased risk of low hemoglobin (Hb) levels due to iron deficiency. Therefore, knowledge of genetic variants associated with low Hb could facilitate individualized donation intervals. We have previously reported three specific single-nucleotide polymorphisms that were associated with ferritin levels in blood donors. In this study, we investigated the effect of these single-nucleotide polymorphisms on Hb levels in 15,567 Danish blood donors.Study Design and Methods: We studied 15,567 participants in the Danish Blood Donor Study. The examined genes and single-nucleotide polymorphisms were 1) TMPRSS6, involved in regulation of hepcidin: rs855791; 2) HFE, associated with hemochromatosis: rs1800562 and rs1799945; 3) BTBD9, associated with restless leg syndrome: rs9357271; and 4) TF, encoding transferrin: rs2280673 and rs1830084. Associations with Hb levels and risk of Hb deferral were assessed in multivariable linear and logistic regression models.Results: The HFE,rs1800562 G-allele and the HFE rs1799945 C-allele were associated with lower Hb levels in men and women, and with an increased risk of Hb below 7.8 mmol/L (12.5 g/dL) in women. Only the rs1799945 C-allele increased the risk of Hb below 8.4 mmol/L (13.5 g/dL) in men. In TMPRSS6, the rs855791 T-allele was associated with lower Hb levels in both men and women, and with an increased risk of low Hb among women.Conclusion: With this study we demonstrate that HFE and TMPRSS6 are associated with Hb levels and risk of Hb below the limit of deferral. Thus, genetic testing may be useful in a future assay for personalized donation intervals. [ABSTRACT FROM AUTHOR]

BACKGROUND: Hemoglobin E‐β0 thalassemia and homozygous β0‐thalassemia are the most common chronic transfusion‐dependent thalassemias in Thailand. Patients with these conditions can experience clinical complications such as RBC alloimmunization. In this study we aimed to determine the prevalence, alloimmunization risk factors, antigenic exposure, and evaluation of antigen‐ (C, c, E, e, Mia) matched RBC transfusion. STUDY DESIGN AND METHODS: Thalassemia patients were recruited from a tertiary care hospital for 10 years from 2008 to 2017. The medical records of transfusion history were reviewed for red cell phenotype both of patients and donors, number of units transfused, and type of alloantibodies. RESULTS: A total of 383 thalassemia patients were identified (178 males and 205 females). The frequency of RBC alloantibodies was 19.3%. Some patients tested positive for more than one antibody type. Autoantibodies were detected in nine individuals. Anti‐E (49 [39.5%]), anti‐Mia (24 [19.4%]), and anti‐c (19 [15.3%]) were the most common antibodies detected. A high rate of alloimmunization was found in splenectomized patients. Risk of alloimmunization increased when more total units of blood had been transfused. A trend toward low alloimmunization rates was noted in the antigen‐matched RBC group, where 3.5% (5/143) of patients were alloimmunized. Anti‐E and anti‐Mia, which may be naturally occurring, were identified in this group. CONCLUSION: Thai patients are more prone to develop antibodies against the Rh and Mia than to the Kell blood group antigens. Provision of at least antigen‐matched (C, c, E, e, Mia) RBCs appears to improve the efficacy of transfusion in thalassemia patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Storage temperature is a critical factor for maintaining red‐blood cell (RBC) viability, especially during prolonged cold storage. The target range of 1 to 6°C was established decades ago and may no longer be optimal for current blood‐banking practices. STUDY DESIGN AND METHODS: Human and canine RBCs were collected under standard conditions and stored in precision‐controlled refrigerators at 2°C, 4°C, or 6°C. RESULTS: During 42‐day storage, human and canine RBCs showed progressive increases in supernatant non–transferrin‐bound iron, cell‐free hemoglobin, base deficit, and lactate levels that were overall greater at 6°C and 4°C than at 2°C. Animals transfused with 7‐day‐old RBCs had similar plasma cell‐free hemoglobin and non–transferrin‐bound iron levels at 1 to 72 hours for all three temperature conditions by chromium‐51 recovery analysis. However, animals transfused with 35‐day‐old RBCs stored at higher temperatures developed plasma elevations in non–transferrin‐bound iron and cell‐free hemoglobin at 24 and 72 hours. Despite apparent impaired 35‐day storage at 4°C and 6°C compared to 2°C, posttransfusion chromium‐51 recovery at 24 hours was superior at higher temperatures. This finding was confounded by a preparation artifact related to an interaction between temperature and storage duration that leads to removal of fragile cells with repeated washing of the radiolabeled RBC test sample and renders the test sample unrepresentative of the stored unit. CONCLUSIONS: RBCs stored at the lower bounds of the temperature range are less metabolically active and produce less anaerobic acidosis and hemolysis, leading to a more suitable transfusion product. The higher refrigeration temperatures are not optimal during extended RBC storage and may confound chromium viability studies. [ABSTRACT FROM AUTHOR]

BACKGROUND There are multiple approaches to the blood product and fluid resuscitation of a bleeding trauma patient. An in silico model of different trauma resuscitation strategies was constructed to predict their effects on the volumes of the different body fluid compartments and on several important hemostatic factors. STUDY DESIGN AND METHODS: This multicompartment dynamic deterministic model comprised four interconnected modules (hemostatic, resuscitation, body fluid compartment, and dilutional coagulopathy). The model was divided into five resuscitation phases with simulations using six different resuscitation strategies: whole blood (WB) only, conventional component therapy (CCT) only or 10 units of WB followed by CCT, with either 1 L of crystalloid or 1.5 units of WB or red blood cells in the prehospital phase. RESULTS: At the end of the simulations using 1 L of crystalloid fluids in the prehospital resuscitation phase, the use of WB led to a 1.4 g/dL higher hemoglobin concentration, 32 mg/dL higher fibrinogen concentration, and 0.9 L lower total extracellular fluid volume compared to CCT. Prehospital blood product transfusion in place of crystalloid resulted in higher hemoglobin and fibrinogen concentrations and a lower international normalized ratio throughout the resuscitation regardless of the resuscitation strategy used. Throughout both the prehospital crystalloid and prehospital blood product transfusion simulations, the hemoglobin and fibrinogen concentrations and platelet counts were higher, and the international normalized ratio was lower, when WB was used compared to CCT. CONCLUSIONS: This model predicted improved hemostatic factor levels and a smaller total extracellular fluid volume volume when WB was transfused instead of CCT to bleeding trauma patients. [ABSTRACT FROM AUTHOR]

Background: The severe forms of thalassemia are the most common inherited anemias managed with regular blood transfusion therapy. Transfusion policies and complications are critical to quality of life and survival, but there is a lack of standardized care.Study Design and Methods: A survey of 58 items was completed in 2016 by 11 centers in California, Washington, Oregon, Nevada, and Arizona providing long-term care for thalassemia. The questionnaire addressed demographic information, transfusion practices and complications, and educational needs.Results: The centers followed 717 patients with β-thalassemia (314, 43.8%) or α-thalassemia (394, 55%). One-third (34.7%) of patients were transfusion-dependent. Indications and goals of transfusion therapy differed between centers. Prestorage leukoreduction was universal, while routine irradiation of units was limited to one site. Red blood cell antigen phenotype was determined before the first transfusion and patients received Rh/Kell-matched units. However, more than half of the transfused patients had received blood at multiple hospitals within or outside the United States. Alloantibodies were seen in 16.9% of transfused group, but management of such patients was variable. Unusual or emerging transfusion-transmitted pathogens were not observed. Multiple educational needs were recognized, with iron overload as the biggest challenge; the approach to iron chelation varied within the group.Conclusion: This study identified many patients not included in earlier surveys limited to major national centers, suggesting that the thalassemia population in the United States is vastly underestimated. Lack of evidence-based guidelines is a barrier to optimal care, which should be addressed through regional consortia of thalassemia centers. [ABSTRACT FROM AUTHOR]