Autologous stem-cell transplantation may be safe without transfusion support

1. In a prospective cohort study of over 120 Jehovah’s Witnesses with lymphoma and multiple myeloma, high-dose chemotherapy (HDC), and autologous stem-cell transplantation (ASCT) without transfusion support was associated with relatively low mortality and morbidities.

Evidence Rating Level: 3 (Average)

Study Rundown: The standard of care for high risk or recurrent lymphoma and multiple myeloma (MM) is high dose chemotherapy (HDC) followed by autologous stem cell transplantation (ASCT). However, patients who refuse blood product transfusions, such as Jehovah’s Witnesses (JW), may encounter medical complications due to concern for bleeding and anemia. The purpose of this prospective cohort study was to describe the mortality and morbidities seen in patients undergoing this treatment regimen without transfusion. Overall, 125 JW were treated with HDC and ASCT and were provided basic blood management techniques (e.g. intravenous iron, limiting phlebotomy). At the conclusion of the trial, the authors found that treatment related mortality at 30 days follow-up was 4.8%. The main adverse events within this cohort were cardiac complications, which occurred in 32% of patients. Furthermore, bleeding complications were low within this cohort. The results of this trial support the safety of ASCT in the JW population without transfusion support. Although the treatment related-mortality is higher than the national average (1%-3.5%), the low rate may be acceptable given the JW’s special characteristic. The study was limited by relatively small sample size. Additional large, prospective trials are needed to confirm the risks and adverse event incidence.

Click to read the study in JCO

Relevant Reading: The threshold for prophylactic platelet transfusions in adults with acute myeloid leukemia

In-Depth [prospective cohort]: This study described the outcome of 125 JW treated with ASCT without transfusion support. The median age at enrollment was 52 years old. The indications for treatment included lymphoma (n=55), multiple myeloma (MM) (n=68), and amyloidosis (n=2). Blood conservation techniques included limited phlebotomy, gastrointestinal and genitourinary bleeding prophylaxis with proton pump inhibitors and hormonal contraceptives, avoidance of heparin and antiplatelet agents, and prophylactic phytonadione. The outcomes of interest were treatment-related mortality (TRM) (mortality after 30 days of ASCT) and adverse events. Overall, TRM occurred in 4.8% of patients (n=6), due to profound anemia (n = 1), severe sepsis (n = 1), multi-organ failure secondary to pancytopenia (n = 1) and cardiac events (n = 3). Cardiac complications occurred in 32% (n=40) of patients, most commonly arrhythmias (n=20), congestive heart failure (n=15), and hypotension (n=17). There were three deaths associated with cardiac complications. There were a total of 18 bleeding episodes, with the majority being grade 1 bleeds (e.g. conjunctival hemorrhage, epistaxis). There were no bleeding-associated mortalities.

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