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Guideline 5.1 Blood Transfusion in People with Anaemia of CKD

Guideline 5.1 Blood Transfusion in People with Anaemia of CKD

We recommend that in people with anaemia of CKD, especially those in whom kidney transplantation is an option, red blood cell transfusion should be avoided, if possible, to minimise the risk of allosensitisation. (1A)

Guideline 5.1.1

We recommend if red blood cell transfusion becomes essential (usually in the setting of acute blood loss, acute haemolysis or severe sepsis) transfusion should be based on policies set by local transfusion guidelines rather than Hb target range for ESA therapy in chronic anaemia of CKD. (1B)

Guideline 5.1.2

We suggest using single unit transfusion, where possible for stable non-bleeding people with CKD who clinically require transfusion. (2C)

Guideline 5.1.3

We suggest that kidney transplant recipients, those on the transplant waiting list or people on immunosuppressive therapy should receive only hepatitis E negative blood components (all UK blood components are tested), but neither CMV negative nor irradiated blood is required. (2B)

Rationale

CKD results in chronic anaemia, the degree of which usually reflects the severity of CKD. As with any chronic anaemia, patients tend to deal with this by various compensatory mechanisms. Blood transfusion is rarely an acute requirement except in emergencies such as acute blood loss, acute haemolysis or severe sepsis/inflammation. Hence the risk benefit ratio of the intervention needs to be analysed before prescribing a red blood cell transfusion to treat anaemia in people with chronic kidney disease.

The potential risks associated with blood transfusion include transfusion reactions, iron overload and transfusion acquired infections. In the presence of severe chronic anaemia, transfusion may lead to congestive cardiac failure, particularly in the elderly. A review of transfusion outcome in people with acute coronary artery syndromes revealed a greater mortality rate in transfusion recipients (1). Another review suggested that treatment of mild to moderate anaemia resulted in increased mortality (2). Also transplant recipient sensitisation may occur following transfusion resulting in longer transplant register waiting times and difficulty in finding a cross match negative donor. A study from Ireland looking at causes of sensitisation of potential allograft recipients showed that the level of sensitisation increased with the number of units of blood transfused and also demonstrated a direct relationship between degree of sensitisation and waiting time for transplantation (3). Blood transfusions can induce antibodies to histocompatibility leukocyte antigens that can reduce the success of kidney transplantation; thus transfusions generally should be avoided in patients awaiting a kidney transplant (2).

The use of ESAs can greatly reduce the need for red blood cell transfusions in people with anaemia of CKD when target Hb concentrations are achieved and maintained (4-5). Since the introduction of ESAs and reduction in routine blood transfusion in people with anaemia and CKD, sensitisation has markedly reduced (6). With the advent of new immunosuppressant regimens after 1995, the use of pre-transplantation transfusion have been rendered largely obsolete (7). The K-DOQI anaemia guideline recommends that no single Hb concentration justifies or requires transfusion and the target Hb recommended for chronic anaemia management should not serve as a transfusion trigger (8). NICE agrees that there are clinical reasons to minimise blood transfusion in anaemia of CKD and if blood transfusion is essential the relevant haematology guidelines should be followed (e.g. the British Society for Haematology (BSH) guidelines https://b-s-h.org.uk/guidelines/guidelines) (8). In hospitalised patients who are haemodynamically stable, the need for transfusion is directed by symptoms and the Hb values. Whilst one study suggested that a value in CKD patients of <70 g/L or <80 g/L in post-operative surgical patients or pre-existing cardiac disease should prompt transfusion, transfusion should be based on patient assessment and policies set by local transfusion guidelines (9).

Hepatitis E virus (HEV) is a RNA virus and has 4 genotypes: the one commonly found in the UK is genotype 3. The most common route of infection in the UK is from eating raw or undercooked meat (particularly pork products) and shellfish; however, HEV can be transmitted via blood transfusion and solid organ transplantation. Incidence of HEV in the UK has been increasing considerably since 2011. It was estimated that as many as 100,000 persons may suffer acute infections each year and that less than 1 in 100 will have any illness at all. The majority of people who become infected with HEV have no symptoms and the infection clears completely within a couple of months. HEV may pose a risk of harm to immunocompromised patients who may be unable to clear the infection, which may then become persistent, potentially leading to chronic inflammation of the liver and cirrhosis. The UK Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) recommends that immunocompromised /immunosuppressed patients should receive HEV negative blood components (10). All blood components in the UK are HEV tested. However, neither irradiated components nor CMV negative components (unless the patient is a neonate or pregnant), are required.

References

  1. Rao SV, Jollis JG, Harrington RA, et al. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA 2004; 292(13): 1555-62.
  2. Zarychanski R, Houston DS. Anaemia of chronic disease: a harmful disorder or an adaptive, beneficial response? CMAJ 2008; 179(4): 333–337.
  3. Soosay A, O’Neill D, Counihan A et al. Causes of sensitisation in patients awaiting renal transplantation in Ireland. Ir Med J 2003; 96(4):109-12.
  4. House AA, Pham B, Pagé DE. Transfusion and recombinant human erythropoietin requirements differ between dialysis modalities. Nephrol Dial Transplant 1998;13(7):1763-9.
  5. Popovsky MA, Ransil BJ. Long-term impact of recombinant human erythropoietin on transfusion support in patients with chronic renal failure. Immunohematology 1996;12(1):1-3.
  6. Manchester Kidney Transplant, NWKTA Audit Project, Jan 2003.
  7. NKF-K/DOQI Clinical Practice Guidelines for Anaemia of Chronic Kidney Disease:2006.
  8. National Institute for Clinical Excellence. Blood transfusion https://www.nice.org.uk/guidance/ng24
  9. Drueke TB, Locatelli F, Clyne N et al CREATE Investigators. Normalization of haemoglobin level in patients with chronic kidney disease and anaemia. N Engl J Ned 2006; 355: 2071-2084
  10. SaBTO (2016) SaBTO/BSBMT Recommendations on the use of HEV-screened blood components https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/2909/sabto_recommendations_on_the_use_of_hev_screened_blood_components.pdf