Whole blood versus red cell concentrates for children with severe anaemia: a secondary analysis of the Transfusion and Treatment of African Children (TRACT) trial
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Date
2022
Journal Title
Journal ISSN
Volume Title
Publisher
The Lancet Global Health
Abstract
The TRACT trial established the timing of transfusion in children with uncomplicated anaemia
(haemoglobin 4–6 g/dL) and the optimal volume (20 vs 30 mL/kg whole blood or 10 vs 15 mL/kg red cell concentrates)
for transfusion in children admitted to hospital with severe anaemia (haemoglobin <6 g/dL) on day 28 mortality
(primary endpoint). Because data on the safety of blood components are scarce, we conducted a secondary analysis to
examine the safety and efficacy of different pack types (whole blood vs red cell concentrates) on clinical outcomes.
Methods This study is a secondary analysis of the TRACT trial data restricted to those who received an immediate
transfusion (using whole blood or red cell concentrates). TRACT was an open-label, multicentre, factorial, randomised
trial conducted in three hospitals in Uganda (Soroti, Mbale, and Mulago) and one hospital in Malawi (Blantyre). The
trial enrolled children aged between 2 months and 12 years admitted to hospital with severe anaemia (haemoglobin
<6 g/dL). The pack type used (supplied by blood banks) was based only on availability at the time. The outcomes were
haemoglobin recovery at 8 h and 180 days, requirement for retransfusion, length of hospital stay, changes in heart
and respiratory rates until day 180, and the main clinical endpoints (mortality until day 28 and day 180, and
readmission until day 180), measured using multivariate regression models.
Findings Between Sept 17, 2014, and May 15, 2017, 3199 children with severe anaemia were enrolled into the TRACT
trial. 3188 children were considered in our secondary analysis. The median age was 37 months (IQR 18–64). Whole
blood was the first pack provided for 1632 (41%) of 3992 transfusions. Haemoglobin recovery at 8 h was significantly
lower in those who received packed cells or settled cells than those who received whole blood, with a mean of 1·4 g/dL
(95% CI –1·6 to –1·1) in children who received 30 mL/kg and –1·3 g/dL (–1·5 to –1·0) in those who received 20 mL/kg
packed cells versus whole blood, and –1·5 g/dL (–1·7 to –1·3) in those who received 30 mL/kg and –1·0 g/dL
(–1·2 to –0·9) in those who received 20 mL/kg settled cells versus whole blood (overall p<0·0001). Compared to whole
blood, children who received blood as packed or settled cells in their first transfusion had higher odds of receiving a
second transfusion (odds ratio 2·32 [95% CI 1·30 to 4·12] for packed cells and 2·97 [2·18 to 4·05] for settled cells;
p<0·001) and longer hospital stays (hazard ratio 0·94 [95% CI 0·81 to 1·10] for packed cells and 0·86 [0·79 to 0·94]
for settled cells; p=0·0024). There was no association between the type of blood supplied for the first transfusion and
mortality at 28 days or 180 days, or readmission to hospital for any cause. 823 (26%) of 3188 children presented with
severe tachycardia and 2077 (65%) with tachypnoea, but these complications resolved over time. No child developed
features of confirmed cardiopulmonary overload.
Interpretation Our study suggests that the use of packed or settled cells rather than whole blood leads to additional
transfusions, increasing the use of a scarce resource in most of sub-Saharan Africa. These findings have substantial
cost implications for blood transfusion and health services. Nevertheless, a clinical trial comparing whole blood
transfusion with red cell concentrates might be needed to inform policy makers.
Description
Keywords
Whole blood, Red cell, Children, Anaemia, Transfusion, Treatment of African Children (TRACT) trial
Citation
George, E. C., Uyoga, S., M'baya, B., Byabazair, D. K., Kiguli, S., Olupot-Olupot, P., ... & Tenu, F. (2022). Whole blood versus red cell concentrates for children with severe anaemia: a secondary analysis of the Transfusion and Treatment of African Children (TRACT) trial. The Lancet Global Health, 10(3), e360-e368.