What is the recommended protocol for blood transfusion in patients undergoing hemodialysis (HD)?

Blood Transfusion Protocol in Hemodialysis Patients

For patients on hemodialysis, blood transfusions should be administered through the intravenous route using a 170-200μm filter giving set, with transfusion completed within 4 hours and time outside temperature-controlled environment restricted to 30 minutes. 1

General Transfusion Considerations for Hemodialysis Patients

• Red blood cell (RBC) transfusions should be stored at a core temperature of 4 ± 2°C with a maximum storage of 28-35 days (depending on adenine addition) 1
• The intravenous route is specifically recommended for patients on hemodialysis receiving erythropoiesis-stimulating agents (ESAs) like darbepoetin alfa 2
• Single-unit RBC transfusions are recommended in hemodynamically stable adult patients without active bleeding 1
• Hemoglobin concentration should be measured before and after every RBC unit transfused, along with clinical assessment 1

Hemoglobin Thresholds for Transfusion in Hemodialysis

• For adult patients with chronic kidney disease (CKD) on hemodialysis, initiate transfusion when hemoglobin levels are less than 7-8 g/dL to reduce transfusion requirements without increasing morbidity or mortality 1
• A restrictive transfusion strategy (Hb threshold 7-8 g/dL) is generally recommended for most hemodialysis patients 1
• For patients with chronic cardiovascular disease on hemodialysis, a slightly higher threshold may be considered, though evidence suggests a threshold of 7.0 g/dL is still sufficient 1

Technical Aspects of Transfusion During Hemodialysis

• Blood can be administered through the venous line of the dialysis circuit, which provides a convenient access point without requiring additional venipuncture 1
• The transfusion should be completed within 4 hours of removing the blood from temperature-controlled storage 1
• Time outside temperature-controlled environment should be restricted to 30 minutes to maintain blood product integrity 1
• Use a standard 170-200μm filter giving set for administration 1

Special Considerations for Hemodialysis Patients

• Evaluate iron status in all hemodialysis patients before and during treatment, as the majority will require supplemental iron during ESA therapy 2
• Administer supplemental iron therapy when serum ferritin is less than 100 mcg/L or when serum transferrin saturation is less than 20% 2
• Monitor for transfusion-associated circulatory overload (TACO), which is a particular risk in hemodialysis patients due to their fluid restrictions and potential cardiac comorbidities 1
• Risk factors for TACO include older age (>70 years), heart failure, renal failure, hypoalbuminemia, low body weight, and rapid transfusion 1

Transfusion Alternatives and Anemia Management

• ESAs like darbepoetin alfa are recommended to reduce transfusion requirements in hemodialysis patients 2
• For adult hemodialysis patients receiving ESAs, the recommended starting dose of darbepoetin alfa is 0.45 mcg/kg intravenously as a weekly injection 2
• Despite ESA use, approximately 23% of hemodialysis patients still require blood transfusions for anemia management 3
• Patients in facilities with the highest prevalence of hemoglobin levels <10 g/dL are at approximately 30% elevated risk of requiring RBC transfusions 4

Potential Complications and Monitoring

• Monitor for febrile, allergic, and hypotensive reactions which can occur within 24 hours following transfusion 1
• Be aware of the risk of alloimmunization in hemodialysis patients who receive multiple transfusions, which can complicate future kidney transplantation 1
• For delayed hemolytic transfusion reactions (DHTRs) with hyperhemolysis in patients with sickle cell disease on hemodialysis, consider immunosuppressive therapy and extended antigen-matched red cells 1
• Passive transfer of hepatitis antibodies can occur through blood transfusions in hemodialysis patients, requiring appropriate monitoring 5

Practical Protocol Summary

1. Assess hemoglobin level and clinical status to determine transfusion need (threshold typically 7-8 g/dL)
2. Use the intravenous route through the dialysis circuit venous line
3. Employ a 170-200μm filter giving set
4. Complete transfusion within 4 hours
5. Monitor vital signs and assess for transfusion reactions
6. Measure post-transfusion hemoglobin level
7. Document transfusion in patient record for tracking purposes