Effect of donor and patient variables on the platelet increment and percent platelet recovery: Experience from tertiary care center in North-Western India

Sarita Sharma; Praveen Kumar Joshi; Sunita Bundas; Amit Sharma

doi:10.4103/gjtm.gjtm_37_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 7 | Issue : 2 | Page : 196-200

Effect of donor and patient variables on the platelet increment and percent platelet recovery: Experience from tertiary care center in North-Western India

Sarita Sharma¹, Praveen Kumar Joshi², Sunita Bundas¹, Amit Sharma¹
¹ Department of Immunohematology and Transfusion Medicine, SMS Medical College and Hospital, Jaipur, Rajasthan, India
² Department of General Surgery, SMS Medical College and Hospital, Jaipur, Rajasthan, India

Date of Submission	29-Apr-2022
Date of Decision	25-Jul-2022
Date of Acceptance	27-Aug-2022
Date of Web Publication	5-Nov-2022

Correspondence Address:
Praveen Kumar Joshi
Department of General Surgery, SMS Medical College and Hospital, Jaipur, Rajasthan
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/gjtm.gjtm_37_22

Abstract

Background and Objectives: Platelet (PLT) deficiency is a common cause of bleeding and PLT transfusions are often indicated for the same. PLT refractoriness is a challenging complication in patients dependent on PLT transfusions. The present study aimed to find out any effect of the donor, recipient, and machine variables on PLT increment (PI) and percent PLT recovery. Patient and Methods: A total of 600 apheresis PLT donors and 600 patients were included in this study; however, the PI and percent platelet recovery (PPR) were analyzed for only 535 patients. The data were collected such as the donor's age, gender, preapheresis hemoglobin (Hb), PLT count, PLT product yield, patient's age, gender, weight, pre- and posttransfusion Hb, and PLT count. PI and PPR were calculated and compared across different groups. Results: Refractoriness was more seen in hematological disorders in comparison to nonhematological disorders (P = 0.00001). However, no significant association of donor and recipient characteristics with PI was seen. Conclusion: PI does not depend on recipient characteristics such as age, gender, pretransfusion PLT count, and Hb.

Keywords: Plateletphereis, platelet yield, platelet increment, percent platelet recovery, platelet refractoriness

How to cite this article:
Sharma S, Joshi PK, Bundas S, Sharma A. Effect of donor and patient variables on the platelet increment and percent platelet recovery: Experience from tertiary care center in North-Western India. Glob J Transfus Med 2022;7:196-200

How to cite this URL:
Sharma S, Joshi PK, Bundas S, Sharma A. Effect of donor and patient variables on the platelet increment and percent platelet recovery: Experience from tertiary care center in North-Western India. Glob J Transfus Med [serial online] 2022 [cited 2023 Mar 28];7:196-200. Available from: https://www.gjtmonline.com/text.asp?2022/7/2/196/360481

Introduction

Platelet (PLT) recovery in the patient is influenced by the transfused dose of PLTs. The quality of the PLT product depends on PLT yield.^[1] Transfusion of high-yield PLT products could reduce the transfusion requirements of a thrombocytopenic patient.^[2] PLT transfusion is a common practice in hemato-oncologic disorders. PLT concentrates can be transfused for therapeutic or prophylactic purposes. Guidelines have been developed based on the current scientific evidence, with the aim to help clinicians to make decisions on PLT transfusion.

The challenge with multiple PLT transfusions is the PLT transfusion refractoriness (PTR).

PLT refractoriness is defined as a repeated suboptimal response to PLT transfusions with lower-than-expected posttransfusion count increments.^[3] PLT transfusion therapy develops a refractory state in patients who receive long-term PLT support. It is due to accelerated destruction. Refractoriness to PLT transfusion is often related to clinical conditions that hasten PLT removal through either immune or nonimmune mechanisms.^[4] Nonimmune factors are responsible for 60%–80% of cases.^[3]

Posttransfusion PLT increments (PIs) should be followed to define PLT refractoriness. The corrected count increment and the percent PLT response (PPR) are the most frequently used formulas for tracking the posttransfusion increment adjusted for the size of the patient and the dosage administered.^[5] An absolute PI of <10 × 10⁹/l after apheresis PLT transfusion in an average-built adult is a good indicator to suspect refractoriness.^[6] A PLT recovery of about 67% in a stable patient indicates a successful transfusion, but the minimum PLT recovery to define a successful transfusion is considered >30% at 1 h posttransfusion and >20% at 20–24 h.^[7]

The present study aimed to find out any effect of donor (age, weight, and hemoglobin [Hb]), recipient (age, sex, weight, pre- and posttransfusion Hb and PLT count, and indication for apheresis PLTs transfusion), machine variables (cell separator and PLT yield) on PI, and percent PLT recovery.

Materials and Methods

This was a prospective study conducted in the Department of Immunohematology and Blood Transfusion of a tertiary care hospital in Northwest India to evaluate the efficacy of PLT transfusions. Data collection were started after the administrative approval of the plan from the ethical committee of the institute.

Platelet donation

Six hundred PLT apheresis single-donor PLT (SDP) donors were selected as per the inclusion and exclusion criteria according to the departmental standard operating procedure (based on the Drug and Cosmetic Act, 1940 amended to date, Government of India). The sample size was calculated at a 95% confidence level and 80% study power. A minimum of 82 donors were required for the study which was increased to 600 donors by the research review board of the institute to increase study power and decrease alpha error.

Donors were counseled, queries answered, and informed written consent was taken. Donors were screened for bilateral venous access. The donor's blood sample (3 ml) was collected in an EDTA vial. Complete blood count (CBC), blood grouping, and transfusion-transmitted disease testing (anti-HBsAg, anti-HIV 1 and 2, anti-HCV, malaria, and syphilis) using rapid test kits were done. The selection of donors for the cell separator was subject to the availability of a particular cell separator at the time of the procedure. All donors found fit to donate were taken to the apheresis room for PLT donation. Apheresis PLTs were collected using cell separators in the department (Amicus/COM.TEC/Haemonetics MCS+). All were single-needle procedures performed using closed system apheresis kits. PLT yield was calculated for each product. CBC was done using an automated cell counter (Sysmex K-4500). The PLT bag was stored at 20°C–24°C with continuous gentle agitation in the PLT agitator until issued. Donors not willing to participate in the study were excluded. All products were issued within 24 h of collection.

Patient and methods

All the requisition forms with SDP demand were screened. The patient's age, sex, diagnosis, pretransfusion PLT count, and pretransfusion Hb were noted. All 600 SDPs were issued to 600 patients but we were able to gather the required information about posttransfusion blood counts in only 535 patients. After 24 h, repeat CBC parameters were ordered to perform to check posttransfusion PI. The report for posttransfusion CBC parameters was collected from the hospital information system. PI and percent PLT recovery (PPR) were calculated 24 h posttransfusion (n = 535).

PI was calculated as posttransfusion count – pretransfusion count and the effect of donor and recipient variables on PI were observed. The PPR was calculated as below resulting in a PPR (PPR standard).^[8]

Based on PPR values, patients were categorized into three groups <20% PPR, 20%–40% PPR, and >40% PPR. PPR ≥20% after 24 h transfusion was considered an adequate response. PPR values were compared across hematological and nonhematological disorders, according to the recipient's weight and donor–recipient sex subgroups. Those patients who did not give consent for the study and PLT transfusion was not done due to any reason, were excluded from the study.

Statistical analysis

Donor characteristics were described using proportions/percentages for qualitative data and using measures of central tendency for quantitative data. Group comparisons were made with the Chi-square test. The arithmetic mean variation of hematological parameters and PLT parameters were compared using the Student's t-test or one-way ANOVA (Analysis of Variance) test. All data were entered into Microsoft Excel and analyzed using IBM SPSS statistics (version 22.0) (IBM SPSS Statistics for Windows, Version 22.0. IBM Corp., Armonk, NY). The statistically significant P value considered was <0.05.

Results

In our study, the total number of patients was 535. The majority were males 323 (60.3%) and 212 (39.6%) were females. The average age of the patient was 30.04 ± 17.07 years. The average age of the male patient was 30.048 ± 17.07 years, whereas for female patients was 30.08 ± 17.14 years. The mean weight of the patient was 54.28 ± 15.73 kg. The mean pre-Hb value was 9.35 ± 2.7 g/dl. The mean PLT count before transfusion was 20144 ± 15872. The mean PI was 32099 ± 27291.

The mean weight of the donor was 73.39 ± 8.7 kg. The mean Hb for a donor was 15.01 ± 1.04 g/dl. The mean donor age was 28.07 ± 5.81. The mean yield of the PLT product was 3.15 ± 0.48. There is no significant difference between donor and recipient characteristics in the percent PLT recovery group [Table 1]. In our study population, all donors were male. All products transfused were ABO and Rh (D) compatible. All products were issued within 24 h of collection. However, we analyzed the outcome of PLT transfusion as PI and percent PLT recovery at 24 h after transfusion.

Table 1: Hematological and demographic profile parameters of patients and platelet apheresis donors

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The majority of SDPs 334 (62.4%) were administered to patients with hematologic diseases. Hematologic disorders included acute myeloid leukemia, acute lymphoblastic leukemia, chronic myeloid leukemia, chronic lymphoblastic leukemia, Hodgkin's disease, NonHodgkin's lymphoma, multiple myeloma, myelodysplastic syndrome, aplastic anemia, thalassemia patients undergoing bone marrow transplant (BMT), and splenomegaly with pancytopenia. Nonhematologic disorders requiring PLT transfusion were 201 (37.57%) comprises dengue fever, pyrexia with thrombocytopenia, various surgical indications such as cardiothoracic surgery, neurosurgery, general surgery, surgeries in urology, and other conditions such as malaria and multiple sclerosis [Figure 1].

Figure 1: Indications of SDP transfusion, SDP: Single-donor platelet

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PI was observed better in surgical patients >NHL >aplastic anemia >hematological malignancies [Table 2].

Table 2: Platelet increment for various medical and surgical indications

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SDP demand was maximum for the patients in the age group of 1–25 years. SDP transfusion was indicated when the PLT count was between 10,000 and 25,000/ul in 330 patients and Hb was between 7 and 10 g/dl in 297 patients. However, no significant relation between donor's age, recipient's age, recipient's sex, recipient's weight, pretransfusion Hb, and pretransfusion PLT count values and PLT yield was observed with PI (P > 0.9–1.0) [Table 3].

Table 3: Analysis of donor and recipient variables on platelet increment

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A significant difference in percent PLT recovery (PPR) was observed between hematological and nonhematological disorders (P < 0.00001). PLT refractoriness was more in patients with hematological disorders in comparison to nonhematological disorders [Table 4]. PLT refractoriness had a significant relationship with weight, patients weighing <25 kg were found more refractory (P < 0.00001). Donor recipient sex mismatch had no significant impact on posttransfusion percent PLT recovery (P = 0.58).

Table 4: Percent platelet recovery variation according to various parameters

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SDP from various cell separators, its subsequent transfusion to the recipient, and analysis of pre- and posthematological values and PI was observed [Table 5]. The difference in pretransfusion Hb levels and posttransfusion Hb levels was statistically insignificant. The difference between pre- and posttransfusion PLT counts was observed statistically significant. Among the three cell separators, the PI was estimated (the difference between pre- and posttransfusion counts) and was observed statistically insignificant (P = 0.727).

Table 5: Pretransfusion and posttransfusion hematological values of patients with respect to different cell separators

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Discussion

The posttransfusion PLT count is affected by the viability of the PLTs and the number of PLTs in the PLT concentrates. It is also affected by the dilution of PLTs in the patient's blood volume.^[8] In our study, the difference in pre-SDP transfusion Hb level and posttransfusion Hb level was statistically insignificant (P < 0.05). The PI was estimated among the three cell separators, it was observed statistically insignificant (P = 0.727), but statistically highly significant posttransfusion increment was there irrespective of the cell separator used for PLT collection. Similarly, a study was done by Enein et al.^[9] evaluated the dose-response effect 12–18 h. After PLT transfusion on 23 patients and observed that the posttransfusion increment increased significantly with the number of PLTs transfused (P < 0.05). We did not find any significant association between PLT yield and PI; this may be due to all the products in our study being single-dose products, with no statistically significant change in yield parameter according to the PPR group.

A challenging complication raised from multiple PLT transfusions is PTR which leads to increased rates of morbidity and mortality. PTR is defined as the lack of adequate posttransfusion PLT count increment. One therapeutic unit of PLTs should increase the PLT count by 35,000/μL–40,000/μL as measured within 10 min and 1 h following the transfusion. Refractoriness to PLT transfusions developed in 32.3% (173) of the patients in our study, out of which the majority had hematological disorders (80.3%). However, further evaluation based on the immune and nonimmune causes of refractoriness was not assessed in our study. Similar results were observed in a study done by Slichter et al., of the 528 patients analyzed, 143 (27%) became PLT refractory.^[10]

In this study, we also analyzed whether donor and recipient sex mismatch influences the outcome of PLT transfusion. There was no significant association between recipient sex and posttransfusion PLT recovery was seen (P = 0.58). However, certain studies show the male sex has been associated with poor response to PLT transfusion in BMT settings.^[11] As all donors were male in our study, we could not access the effect of female donor PLT product on the male recipient

No significant difference between recipient and donor characteristics such as age, sex, pretransfusion Hb value, pretransfusion PLT count, and PLT yield was observed with PI. PLT refractoriness had a significant relationship with weight in our study; patients weighing <25 kg were found more refractory (P < 0.00001). The most common cause of refractoriness was nonimmunological followed by immunological. Nonimmune causes involve nearly 80% of PTR episodes, being the most frequently reported infection/sepsis, fever, disseminated intravascular coagulation, splenomegaly, graft versus host disease, and antibiotics.^[6]

All apheresis PLTs in the study were ABO compatible and were issued within 24 h of collection. The same was recommended by other studies which state that PLT factors that are associated with improved PLT responses are giving ABO-compatible PLTs,^[12] PLTs stored for 48 h^{[13],[14],[15]} or less, and giving large doses of PLTs, whereas ultraviolet B or gamma irradiation are associated with decreased PLT responses.^[16] Hence, these factors should be kept in mind while issuing the PLT product as a transfusion medicine specialist and while transfusing the same as a clinician.

Strength and limitations of the study

All SDPs transfused were ABO compatible and transfused within 24 h of collection. No such study on such a large patient population has been done in India where PLT transfusions are common. However, our study had a few limitations. All donors were males so the findings may not be generalized to a larger population of donors and further studies are needed. The volume of intravenous fluids and other blood components concomitantly transfused with PLTs and their effect on blood volume were not studied.

Conclusion

PI does not depend on recipient characteristics such as age, gender, pretransfusion PLT count, and Hb. However, further studies are required to see this effect. Short storage time and ABO compatibility should be considered during PLT transfusion.

Ethical approval statement

The study was approved by the Institutional Ethical Committee.

Acknowledgments

The authors acknowledge all the donors, patients, and clinicians who participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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