Thread by @TransfusionWM

Recently, blood bank brought to my attention a patient under haematology who was pancytopenic.

Hb 77 g/L
WCC 8.4 x10^9/L
Plt 41 x10^9/L

What is the usual red cell transfusion threshold for patients with haematological malignancy?

#blooducation

In the absence of active bleeding or acute coronary syndrome, NICE recommend a transfusion threshold of 70 g/L. Some haematology units use 80 g/L although this is not supported by UK guidance.

nice.org.uk/guidance/ng24/…

There are a few RCTs in haematology patients but we can discuss those another time!

Patients with chronic transfusion dependent anaemia should be transfused to individualised thresholds depending on symptoms.

The patient had a new diagnosis of Waldenstrom's macroglobulinaemia. This is a clonal disorder of lymphoplasmacytoid cells where an excess of IgM is produced. Because IgM is a pentamer, this can lead to increased plasma viscosity.

When would you transfuse red cells to a patient with hyperviscosity syndrome?

As tranfusion will further increase viscosity, it should only be given if the patient is very symptomatic with severe anaemia. Ideally, reduce the plasma viscosity first.

The patient developed epistaxis. What treatment is indicated?

Hyperviscosity symptoms include skin and mucosal bleeding, visual disturbance secondary to retinopathy, neurological symptoms and cardiac failure. Although the pt is thrombocytopenic, this is unlikely the cause of bleeding.

A platelet count above 30 is sufficient for minor bleeding and transfusion is not indicated. See BSH guidelines for further info on indications for platelet transfusion onlinelibrary.wiley.com/doi/full/10.11…

The patient requires urgent definitive management of their hyperviscosity.

I hope you enjoyed this little #tweetorial on transfusion in Waldenstrom's!

See @BritSocHaem guidelines for diagnosis and management of WM, including management of hyperviscosity.

onlinelibrary.wiley.com/doi/full/10.11…