Blood Transfusion for Severe Anemia in Hemodialysis Patient
For a 100kg hemodialysis patient with hemoglobin 5.3 g/dL, transfuse 2 units of packed red blood cells initially, reassessing hemoglobin and clinical status after each unit before administering additional blood. 1
Immediate Transfusion Decision
Transfusion is almost always indicated when hemoglobin is <6 g/dL, particularly when anemia is acute, and a hemoglobin of 5.3 g/dL falls well below this critical threshold where transfusion provides clear benefit. 1
The restrictive transfusion threshold of 7 g/dL recommended for stable patients does not apply at hemoglobin 5.3 g/dL—this level requires immediate intervention regardless of hemodynamic stability. 1, 2
For hemodialysis patients specifically, while the target hemoglobin range for chronic management is 11.0-12.0 g/dL with erythropoiesis-stimulating agents, acute severe anemia at 5.3 g/dL necessitates transfusion before initiating ESA therapy. 3, 2
Transfusion Protocol
Administer packed red blood cells one unit at a time, measuring hemoglobin after each unit to guide further transfusion decisions. 3, 1
Each unit of packed red blood cells should increase hemoglobin by approximately 1-1.5 g/dL in a 100kg patient. 1
For this patient, expect to need 3-4 units total to reach a safe hemoglobin level of 7-8 g/dL, but never transfuse all units at once—reassess clinically and measure hemoglobin between each unit. 1
Complete each transfusion within 4 hours of removal from controlled storage, monitoring vital signs pre-transfusion, at 15 minutes, and at completion. 4
Post-Transfusion Management
After achieving hemoglobin 7-8 g/dL through transfusion, initiate erythropoiesis-stimulating agent therapy targeting hemoglobin 11.0-12.0 g/dL for long-term management. 2, 5
Check serum ferritin and transferrin saturation before starting ESA therapy—administer supplemental iron when ferritin is <100 ng/mL or transferrin saturation is <20%. 3, 5
The recommended starting ESA dose for hemodialysis patients is 0.45 mcg/kg weekly (approximately 45 mcg weekly for this 100kg patient) administered intravenously at the end of dialysis sessions. 5
Critical Pitfalls to Avoid
Do not delay transfusion to initiate ESA therapy first—ESAs are not a substitute for red blood cell transfusions when immediate correction of severe anemia is required. 5
Avoid transfusing to hemoglobin >10 g/dL acutely, as higher targets increase risks of cardiovascular events, volume overload, and transfusion-associated complications without additional benefit. 3, 1
Hemodialysis patients lose 15-25 mL of whole blood per dialysis session (approximately 60 mL per week) from blood retention in the dialyzer and phlebotomy, requiring ongoing iron supplementation during ESA therapy. 3
Monitor for transfusion reactions including fever, hypotension, tachycardia, or dyspnea—if any develop, stop the transfusion immediately and contact the blood bank. 4