Transfusion management of severe anaemia in African children: a consensus algorithm

Abstract

The phase III Transfusion and Treatment of severe anaemia in African Children Trial (TRACT) found that conservative management of uncomplicated severe anaemia [haemoglobin (Hb) 40-60 g/l] was safe, and that transfusion volume (20 vs. 30 ml/kg whole blood equivalent) for children with severe anaemia (Hb <60 g/l) had strong but opposing effects on mortality, depending on fever status (>37·5°C). In 2020 a stakeholder meeting of paediatric and blood transfusion groups from Africa reviewed the results and additional analyses. Among all 3196 children receiving an initial transfusion there was no evidence that nutritional status, presence of shock, malaria parasite burden or sickle cell disease status influenced outcomes or modified the interaction with fever status on volume required. Fever status at the time of ordering blood was a reliable determinant of volume required for optimal outcome. Elevated heart and respiratory rates normalised irrespective of transfusion volume and without diuretics. By consensus, a transfusion management algorithm was developed, incorporating three additional measurements of Hb post-admission, alongside clinical monitoring. The proposed algorithm should help clinicians safely implement findings from TRACT. Further research should assess its implementation in routine clinical practice.

Keywords: African children; anaemia; guidelines; malaria; transfusion.

Fig 1. Transfusions given in the TRACT trial.

Fig 2. Algorithm for managing suspected/confirmed severe anaemia.

Fig 3. (A) Morality at 28 days by subgroups for the immediate vs control timing of transfusion comparison. (B) Morality at 28 days by subgroups for the transfusion volume comparison. PfHRP2, plasma Plasmodium falciparum histidine-rich- protein 2.

Fig 4

(A) Time to Transfusion in Immediate vs Control Comparison. (B) Cumulative incidence in second transfusion in the 30 mls/kg vs. 20 mls/kg split by fever and no fever. Note: A competing risks analysis with discharge, absconding and death as competing events. There are 39 transfusions given after 120 h from baseline not included on the graph. [Colour figure can be viewed at wileyonlinelibrary.com]

Fig 5. Justification for transfusion volume management based on initial temperature and not on subsequent temperatures.