From the Guidelines
Blood transfusion in dialysis patients should be guided by a target hemoglobin of 70-90 g/L, as recommended by the most recent guidelines 1.
Key Considerations
- The transfusion should ideally be administered during the dialysis session through the venous line of the dialysis circuit after the dialyzer.
- The recommended rate is typically 1 unit of packed red blood cells (PRBCs) over 2-4 hours, with close monitoring of vital signs every 15 minutes for the first hour and then hourly.
- Pre-medication with acetaminophen 650 mg orally and diphenhydramine 25-50 mg orally or IV may be given 30 minutes before transfusion to prevent reactions.
- Ultrafiltration rates should be adjusted during transfusion to prevent fluid overload, as each unit of PRBCs adds approximately 250-350 mL of volume.
Rationale
The management of anemia in dialysis patients has evolved, with a focus on minimizing blood transfusions due to the risks of iron overload and other complications 1.
Monitoring and Adjustments
- Monitoring for transfusion reactions is essential, with particular attention to signs of fluid overload such as dyspnea, hypertension, or pulmonary edema.
- Adjustments in ultrafiltration rates and close monitoring of the patient's condition are crucial to prevent complications.
Conclusion is not needed, the above is the answer.
From the Research
Transfusion Guidelines
- The decision to transfuse blood in dialysis patients should be made based on individual patient needs and symptoms, rather than relying solely on hemoglobin levels 2.
- For patients with iron-deficiency anemia, alternative methods to improve hemoglobin levels should be tried first before considering transfusion 2.
- In patients with acute upper gastrointestinal bleeding, transfusion is recommended for hemoglobin levels less than 7 g/dL 2.
- For patients with chronic ischemic heart disease, transfusion is recommended for hemoglobin levels less than 8 g/dL or if they are symptomatic 2.
Effects of Transfusion on Dialysis Patients
- Red cell transfusion has been shown to raise intradialytic pressure and reduce the frequency of intradialytic hypotension in dialysis patients 3.
- Patients with mean hemoglobin levels less than 10 g/dL are more likely to receive transfusions, with a risk ratio of 2.2 compared to those with hemoglobin levels greater than or equal to 10 g/dL 4.
- The risk of transfusion increases substantially with hemoglobin concentrations less than 10 g/dL, and appears to be independent of other clinical factors 4.
Transfusion Sets and Hemolysis
- The type of blood transfusion set used can affect the level of red blood cell hemolysis, with microdrop sets resulting in a higher degree of hemolysis at infusion rates of 10 mL/h 5.
- The level of free hemoglobin and degree of hemolysis increase postinfusion, regardless of the type of transfusion set used 5.
Hemoglobin Targets and Transfusion Requirements
- High hemoglobin targets (13.5-14.5 g/dL) may reduce the need for transfusions in hemodialysis patients without symptomatic cardiac disease receiving erythropoietin therapy 6.
- Transfusion rates are lower in patients with high hemoglobin targets, with a rate of 0.26 units of blood per year compared to 0.66 units per year in patients with low hemoglobin targets 6.