Background
Anaemia is defined as reduction below normal limits of the total circulating red cell mass. It is measured by the reduction in packed red cell volume or reduction in haemoglobin concentration of blood. Based on etiology anaemia can be classified into anaemia due to decreased production of red cells, anaemia due to increased destruction of red cells and anaemia due to acute blood loss. 1, 2
Patients with hemoglobin below 6 gm/dl usually require transfusion therapy. In stabilized patients with hemoglobin values between 6 and 10 gm/dl, the decision whether to transfuse is based on an evaluation of clinical status. Patients with value above 10 gm/dl rarely require transfusion.3, 4, 5 Initially whole blood was transfused but now it is replaced by packed red cells after the advent of proper refrigeration, component separation method(platelet rich plasma method and buffy coat method)and anticoagulants especially additive solution SAGM(saline adenine dextrose and mannitol) and polyvinylchloride(PVC) blood bags such as di-2-ethylhexylphthalate(DEHP) and tri-2-ethylhexyl trimellitate(TEHTM). 6, 7
Packed cells are particularly valuable in treating patients whose blood volumes are normal and corrects the anemia without increasing blood volume, thereby preventing circulatory overload. Other indications are symptomatic iron deficiency anaemia, severe anaemia in chronic kidney diseases, congestive cardiac failure patients, severe symptomatic anaemia in anaemia of chronic disease, anaemia due to chronic blood loss, certain haemolytic anaemias, anaemia associated with dialysis, anaemia of pregnancy and acute blood loss anaemia(transfused along with crystalloid or colloid). 8, 9
Previously there was a concept that whole blood or fresh blood will improve the condition because of the activity of 2,3Diphosphoglycerate, however recent studies show that transfusion of packed cells have helped in increasing hemoglobin with restoration of 2,3Diphosphoglycerate activity and thereby correcting anemia and also correction of hypoxia. 10, 11
With this background the current study will be performed to assess the effects of packed red cell transfusion in our patients by comparing pre and post transfusion hematological parameters.
Aim of the Study
To analyze the effect of packed red cells transfusion in anemic patients by comparing pre and post transfusion hematological work up.
Materials and Methods
The present study comprised of 140 cases who are diagnosed to be anaemic based on clinical as well as on laboratory date who received packed red cell transfusion in our hospital. The study was commissioned after ethical committee clearance.
Data collection tools
Pre transfusion - Clinical details and examination
Post transfusion - All the pre transfusion details are collected again and compared.
Haemoglobin percent, PCV, Red blood cell indices were collected by running anticoagulated blood in automated haematology analyser. Peripheral smear is prepared by manual spreading and stained by using Leishman’s stain. Reticulocyte count by using new methylene blue stain.
Results & Observations
In the present study 140 patients with anaemia who underwent packed red cell transfusion were studied by using haematological parameters and subdivided into following disease groups. Out of 140 patients 45(34.6%) of patients were clinically diagnosed as iron deficiency anaemia followed by 43(33.1%) anaemia of chronic disease patients, 18(13.8%) of anaemia of chronic kidney disease, 20(15%) of anaemia of liver disease, 10(7.7%) of dimorphic anaemia and 4(3.1%) of anaemia in hypersplenism.Table 1
Table 1
Types of disease group studied
Iron deficiency anaemia is the most common disease group in the present study followed by anaemia of chronic disease.Table 2
Table 2
Age distribution of anaemia based on disease group
Iron deficiency anaemia is more prevalent in the third and fourth decade. Anaemia of chronic disease in the fifth and sixth decade.Table 3
Table 3
Sex distribution irrespective of disease group
|
Sex |
No. of patients |
Percentage |
|
Male |
57 |
43.8 |
|
Female |
73 |
56.2 |
Anaemia is more prevalent in the female population. M:F ratio is 4:5.Table 4
Table 4
Sex distribution of anaemia based on disease group
|
|
Male |
Female |
|
Iron dediciency anaemia |
12 |
33 |
|
Anaemia of chronic disease |
19 |
24 |
|
Anaemia of chronic kidney disease |
10 |
8 |
|
Anaemia of liver disease |
19 |
1 |
|
Dimorphic anaemia |
6 |
4 |
|
Anaemia in hypersplenism |
2 |
2 |
Iron deficiency anaemia is more in female population. M:F ratio is 1:3.Table 5
Table 5
Haemoglobin values compared before and after transfusion based on disease group
Table 6
Mean increase in HB after one unit of transfusion based on disease group(P value calculated by applying paired t test)
Iron deficiency anaemia, anaemia of ACD, anaemia of CKD and Dimorphic anaemia shows desirable improvement in Hb. Anaemia of liver disease and anaemia in hypersplenism does not shows desirable improvement.
Table 7
Mean increase in HB after two unit of transfusion based on disease group (P value calculated by applying paired t test)
In iron deficiency anaemia, pre transfusion peripheral smear picture of all 45 patients was microcytic hypochromic. After transfusion 39 patients remains as microcytic hypochromic and 6 patients showed microcytic hypochromic with normochromic cells.
Figure 1
Comparison of pre and post transfusion peripheral smear patterns in anaemia of chronic disease
Figure 2
Comparison of pre and post transfusion peripheral smear patterns in anaemia of chronic renal disease
Figure 3
Comparison of pre and post transfusion peripheral smear patterns in dimorphic anaemia (anaemia of combined deficiency)
In anaemia of combined deficiency peripheral smear remains same as pre transfusion.
Figure 4
Comparison of pre and post transfusion peripheral smear patterns in anaemia of liver disease
In anaemia of liver disease pre transfusion peripheral smear 6 patients shows predominantly macrocytic and microcytic cells, remains same after transfusion.4 patients show predominantly microcytic hypochromic with macrocytes.
Figure 5
Comparison of pre and post transfusion peripheral smear patterns in anaemia in hypersplenism
In anaemia in hypersplenism, peripheral smear remains same as pre transfusion.
Discussion
Packed red cell transfusion plays an important role in treatment of symptomatic anaemia patients, in order to improve the clinical status. Previous literature discusses the improvememnt of survival, mortality and morbidity through transfusion in various clinical types of anemia. The present study discusses the improvement of various hematological parameters and thereby improvement of survival indirectly, in comparison with literature. 1, 2, 6
In the present study 130 patients with anaemia who underwent packed red cell transfusion were reviewed by using haematological parameters and subdivided into following disease groups. Out of 140 patients 45 (34.6%) of patients were clinically diagnosed as iron deficiency anaemia followed by 43 (33.1%) anaemia of chronic disease patients, 18(13.8%) of anaemia of chronic kidney disease, 20(15%) of anaemia of liver disease, 10(7.7%) of dimorphic anaemia and 4 (3.1%) of anaemia in hypersplenism. 7, 9
Iron deficiency anaemia is more prevalent in the age group of 31-40, followed by age group of 41- 50. Anaemia of chronic disease is more in the age group of 61-70 followed by 51-60. Anaemia of chronic kidney disease is equally distributed in the age group of 41-70. Anaemia of liver disease is more in the age group of 41-50. Dimorphic anaemia is more prevalent in the age group of 71-80. 10, 11
In this study anaemia was more prevalent among the females 56.2% followed by males 43.8%, particularly iron deficiency anaemia is more prevalent among females with 72.34%. Anaemia of chronic disease and anaemia of chronic kidney and dimorphic anaemia have almost equal sex distribution. Anaemia of liver disease is more prevalent among males with 90%. According to WHO Global Database on Anaemia Bruno de Benoist et al worldwide prevalence of anaemia in non pregnant women is 30.2% and number of women affected in million is 468.4. 12
Iron deficiency anaemia
In this study iron deficiency anaemia is more prevalent than other anaemias. Also it is the most common anaemia in the female of reproductive age group. The reasons are negative iron balance, increased iron loss and increased iron requirement. Negative iron balance is due to decreased iron intake because of nutritional deficiencies, poor socioeconomic status. The increased prevalence of iron deficiency among the economically deprived people in developing countries is explained in part by the fact that heme iron is less abundant in their diets and women are usually smaller and consume less food and their requirements are greater, so their daily iron intake may be marginal. 13
Improvement in hemoglobin concentration could be observed 24hour after transfusion of one unit of packed red cells is 1gm/dl. Sally A, Campbell-L et al says that one unit of packed red cells should raise the haemoglobin of an average adult by 1gm/dl and haematocrit by 3%. 14
In the present study the mean increase in Hb after transfusion was 0.97gm/dl(P value-0.01) and PCV of 3(P value-0.02). There is desirable increase and patient condition also improved with concurrent iron, vitamin B12 and folic acid therapy which is appreciated one week after administration of therapy by monitoring the reticulocyte count in younger age group. But in the older patients 5 in no, degree of improvement after initiation of therapy was low as the marrow response was poor. Packed red cell transfusion is not always necessary in anaemia of combined deficiency, but its of valuable in severe grade anaemia and in symptomatic anaemia patients.
Conclusion
From this background the present study concludes that before planning transfusion in anaemic patients, accurate clinical assessment and work up for type of anaemia is essential. After transfusion of one unit of packed red cells in chronic anaemia patients, assessment of symptoms immediately after transfusion and post-transfusion Hb levels should be done.
It is also important that, in cases of anaemia of chronic disease and critically ill patients, a restrictive statergy of blood transfusion must be followed in order to avoid unnecessary transfusion and its complications.
In all the types of anaemia studied, the mean increase in Hb and PCV values were statistically more significant (Pvalue<0.05). Hence Hb and PCV can be taken as valuable parameters to monitor the post transfusion outcome.
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