Should we transfuse packed red blood cells (PRBCs) now given the patient's declining hemoglobin (Hgb) level and dependence on dialysis?

From the Guidelines

Transfusion of packed red blood cells (PRBCs) is recommended for this dialysis-dependent patient with a hemoglobin level of 7.0 g/dL, as the patient's hemoglobin has been trending down and is below the generally accepted threshold of 7-8 g/dL for transfusion in dialysis patients. For dialysis patients, a hemoglobin target of 10-11 g/dL is generally appropriate, with transfusion typically considered when levels fall below 7-8 g/dL or if the patient is symptomatic 1. Assess for symptoms of anemia such as chest pain, shortness of breath, fatigue, or tachycardia, as these would strengthen the indication for transfusion. The rate of hemoglobin decline is also important; a rapid drop may warrant more urgent transfusion. When transfusing, administer one unit of PRBCs at a time and reassess, as dialysis patients are at risk for volume overload. Consider timing the transfusion during dialysis if volume concerns exist. Remember that frequent transfusions can lead to iron overload and allosensitization, potentially complicating future kidney transplantation. Simultaneously, investigate and address the underlying cause of the declining hemoglobin, which might include blood loss, inadequate erythropoietin, iron deficiency, or other factors specific to kidney disease. According to the most recent guideline from the AABB, a restrictive transfusion strategy (7 to 8 g/dL) is recommended for hospitalized, stable patients 1.

Some key points to consider:

• The patient's hemoglobin level is below the recommended threshold for transfusion in dialysis patients
• The patient's symptoms and rate of hemoglobin decline should be taken into account when making the decision to transfuse
• Transfusion should be done cautiously, with one unit of PRBCs at a time, and with reassessment after each unit
• The underlying cause of the declining hemoglobin should be investigated and addressed
• Frequent transfusions can lead to complications such as iron overload and allosensitization.

It's worth noting that the evidence from 1 suggests that transfusion decisions should be based on a full clinical assessment of the patient, rather than just the hemoglobin level. However, the guideline from 1 provides a clear recommendation for a restrictive transfusion strategy in hospitalized, stable patients.

In this case, given the patient's low hemoglobin level and dependence on dialysis, transfusion of PRBCs is the most appropriate course of action, with careful consideration of the patient's symptoms, rate of hemoglobin decline, and underlying cause of the anemia 1.

From the Research

Patient's Condition

• The patient, ALONSO KRISANNE, has a hemoglobin (Hgb) level of 7.0 g/dL, which has been trending down from 8.9 g/dL.
• The patient is on dialysis and was unable to have their blood pressure (BP) taken.

Transfusion Considerations

• According to the study 2, in patients with acute upper gastrointestinal (GI) bleeding, transfusion is recommended for hemoglobin levels less than 7 g/dL.
• The patient's current Hgb level is 7.0 g/dL, which is very close to this threshold.
• Another study 3 suggests that the decision to transfuse should be made according to the patient's individual status, taking into account their co-morbidities and severity of disease.

Dialysis Patients and Hemoglobin Levels

• A study 4 found that aiming for a hemoglobin level above 12 g/dL in dialysis patients may increase the risk of death and cardiovascular complications.
• The same study suggests that the current literature does not support an upper Hgb target above 12 g/dL for dialysis patients.
• Another study 5 discusses the importance of anemia management in patients receiving chronic hemodialysis, including the use of erythropoiesis-stimulating agents (ESAs) and iron supplementation.

Potential Course of Action

• Considering the patient's declining Hgb level and dependence on dialysis, transfusion of packed red blood cells (PRBCs) may be necessary to maintain or restore the oxygen-carrying capacity of the blood.
• However, the decision to transfuse should be made on a case-by-case basis, taking into account the patient's individual status, co-morbidities, and severity of disease, as suggested by the study 3.
• It may be beneficial to repeat the Hgb level later to determine if transfusion is necessary, but this decision should be made in consultation with the patient's healthcare team, considering the potential risks and benefits of transfusion, as discussed in the study 6.