Twenty Units of Blood and Counting

Iron overload is a condition seen in patients who have received multiple packed red cell transfusions. Generally, patients who have received >20 transfused units will be at risk. Currently in Australia there is no universal method of tracking the number of transfusions a patient has received, and a cumulative figure requires manual calculation. Therefore, identification of at-risk patients is not straightforward.

Aim: Firstly, to review the primary diagnosis of transfused patients in haematology day units. Secondly, to quantify number of transfusions received and serum ferritin levels of transfused patients. Thirdly, to review the use of iron chelation in these patients and document potential reasons for non-chelation including co-morbidities and concomitant medications.

Method: Medical records for outpatients transfused during the 12-week index period (12 consecutive weeks from Human Research and Ethics Commitee/institution approval) were reviewed in this retrospective multicentre audit. Data were captured using a piloted data collection form. Non-parametric statistical test have been used.

Results: To date, 237 patients, aged 0–95 have been reviewed from 10/20 centres. Common underlying conditions necessitating transfusion were: MDS(35%), chemotherapy-induced anaemia(21%) and thalassaemia(14%). The medical record of 26% patients indicated that transfusions had also been given elsewhere. In total, 119 had received >20units, 58(49%) had been prescribed chelation therapy. Fourteen patients who had received >20units had no documented serum ferritin. Patients receiving iron chelation were younger (median 42 cf.73 years, p=0.0004), had received more transfusions(median 60 cf.18, p<0.0001) and more units(median 187 cf.37, p<0.0001). There was no difference in number of concurrent medical conditions(p=0.73) or concomitant medications(p=0.14). Life expectancy was documented for 6 patients only, 3 were chelated.

Conclusion: There is variability in the monitoring and treatment of iron overload in Australian hospitals, with not all at-risk patients receiving chelation. The development and implementation of universal tracking tools for transfusion nurses and patients may be one means of improving identification of at-risk patients.