Blood and platelet transfusions for aplastic anaemia

Transfusions do not repair the marrow, but they can carry you through

A transfusion does not repair the bone marrow. It supplies red cells or platelets that the marrow is not making in enough numbers, and that gap shapes daily life: how tired you feel, whether you bruise. Why the marrow falls short in the first place is explained in how bone marrow makes blood.

This page covers the main blood products, what a session involves, irradiated blood, iron build-up, infection and growth factors. For the wider picture, start with the treatment overview.

Transfusions as supportive care

Transfusions belong to what doctors call supportive care. They run alongside treatments that aim to change the underlying disease, such as immunosuppressive therapy. The British Society for Haematology guideline on adult aplastic anaemia lists blood and platelet transfusion, antimicrobial prophylaxis and prompt management of opportunistic infections as key throughout the disease course. Needing transfusions does not on its own mean treatment has failed.

Red cell transfusions and what a session is like

Red cells carry oxygen around the body. When the count runs low, people often feel exhausted and breathless. The Aplastic Anaemia Trust notes that one unit of red cells typically raises haemoglobin by about 10 g/L, and that how often transfusions are needed depends on many factors, so there is no single schedule that suits everyone.

Every unit is matched to your blood group before it is given. Sessions usually take place in hospital and rarely need an overnight stay. Many people use a cannula in the hand, but frequent transfusions are often given through a central line such as a Hickman or PICC line. A bag of red cells can take up to four hours, though most take one to two.

During a transfusion, a few people get fever, chills, a rash or shaking. Staff can treat these, sometimes with simple medicines or by slowing the transfusion, so say something as soon as you feel unwell. Red cells may be given cautiously, sometimes with water tablets, especially over 70, to avoid fluid building up in the lungs.

Platelet transfusions, and why thresholds vary

Platelets help blood clot. Teams commonly give them to prevent bleeding when the count falls below 10 x 10^9 per litre, or below 20 if there is a fever, and to treat active bleeding, depending on how serious it is and where it is. A platelet transfusion is usually given over about 30 minutes. Thresholds shift around surgery, ATG treatment and bleeding symptoms.

Response varies a great deal from person to person. A single unit typically raises the count by 10 to 40 x 10^9 per litre, and the effect usually lasts about two to five days. Some people make antibodies against platelets, which means specially selected donors have to be found, and some need platelets matched on human leukocyte antigens, which must be ordered well in advance.

Why some blood must be irradiated

Irradiated blood has been treated with radiation so that donor white cells in it stop dividing. Without that step, transfused white cells can attack the recipient in a serious immune reaction called transfusion-associated graft-versus-host disease, or TA-GvHD. NHS Blood and Transplant explains that only certain patients are at risk, and that irradiation has no significant effect on how well red cells or platelets work.

The Aplastic Anaemia Trust lists irradiated products as a requirement for people who are planned for, or have had, ATG, and for people who have had a bone marrow transplant. Red cells are irradiated on demand rather than routinely, and they have a shorter shelf life once irradiated. Platelets are routinely irradiated in Northern Ireland, Scotland and Wales, but in England only when needed.

Confirm before each transfusion that the blood is irradiated, and show your card, especially at a hospital you do not usually attend.

Iron overload and chelation

Each unit of red cells carries iron that the body cannot easily remove. Iron can build up in the liver, heart and pancreas and injure them over time. The Aplastic Anemia & MDS International Foundation adds that for some people this takes many years, but for others it can happen after as few as 10 to 15 transfusions, which is 20 to 30 units of red cells.

Screening usually starts at diagnosis, with blood tests that show how much iron is stored, and it is repeated after about 20 units of blood. Keep count of the units you receive if you can, because your team needs that number to judge risk.

Treatment uses iron chelators, drugs that help the body clear extra iron. Deferasirox is taken as a tablet by mouth, and deferoxamine is given through a small pump worn under the skin, usually at night. Your team will monitor your liver and kidneys and check your hearing and eyesight. Until they say otherwise, avoid iron supplements and multivitamins that contain iron.

Infection prevention and neutropenic fever

Low neutrophils make infections more likely and harder to clear. Depending on your counts and history, teams may prescribe preventive antibiotics, antifungal drugs or antiviral drugs, in line with the prophylaxis focus of the guideline discussed above.

Neutropenic fever is an emergency. If you develop a fever while your neutrophils are low, or feel unwell in any way, call your team straight away rather than waiting. A fever during a transfusion is taken seriously too. In someone with low neutrophils it may need intravenous antibiotics for a few days, even if the transfusion seems to be the cause, because it could still be infection. The Aplastic Anaemia Trust explains this.

Call the hospital team now if you have:

• a fever, chills, or feeling generally unwell
• difficulty breathing, or new chest or back pain, especially within a day of a transfusion
• bleeding that is heavy or will not stop

Ask your haematology team which precautions apply to you.

Growth factors in general

Growth factors are signals that prompt the marrow to make more of a particular cell type. The Aplastic Anemia & MDS International Foundation notes that red cell growth factors are generally not effective in severe or very severe aplastic anaemia, because there are too few stem cells in the marrow for them to stimulate. They may be considered after immunosuppressive therapy, once stem cells begin to return.

White cell growth factors can help the body fight infection when neutrophils are low. Side effects vary by drug, and often include bone or muscle pain, headache and fever. For platelet growth factors such as eltrombopag, see immunosuppressive therapy.

Frequent hospital visits can be hard to fit around work or family. Tell the team early if transfusion days cause strain, since they may help you plan around them. For day-to-day advice, see living with bone marrow failure.

Matching, monitoring and early calls keep transfusion safe

Transfusion is a safe procedure, and the risk of harm from it is very low, as The Aplastic Anaemia Trust puts it. The details still matter: matched blood, irradiated products when needed, and a prompt call when a fever appears.