Red cell alloimmunisation in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO)
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LETTER
Red cell alloimmunisation in patients receiving veno‑venous extracorporeal membrane oxygenation (VV‑ECMO) Deepa R. J. Arachchillage1,2,3*, Steve Owen1, Maria Anievas1, Mihaela Gaspar1 and Mike Laffan2,3 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Dear Editor, Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is lifesaving for patients with severe respiratory failure. These patients require frequent repeated red cell transfusion which can lead to development of alloantibodies against red cell (RC) antigens, complicating subsequent transfusions. The frequency of alloimmunisation in patients receiving EMCO is unknown. Although the optimal transfusion threshold for patients receiving VV-ECMO remains controversial, our threshold is a haemoglobin (Hb) of ≤ 70 g/L compared to 12 days vs. 9 (7–11.5) days]. Clinically significant bleeding and haemolysis occurred in 22.3% (40/179) and 1.1% (2/179), respectively, of the patients in our cohort. The natural history of patients who develop red cell alloimmunisation is unknown. It is possible that once the acute inflammatory response is settled, antibodies may
in patients receiving VV-ECMO was similar to that reported in patients who received repeated RC transfusion for haemoglobinopathies (3%) where all alloimmunised patients received more than 10 RC units (range 18–152) in 6 months or more prior to the development of RC antibodies [3]. The similar frequency of immunisation on ECMO but after fewer transfusions may result from the acute inflammatory process in patients receiving VV-ECMO which can predispose to development of alloantibodies and may warrant frequent monitoring for development of alloantibodies. Fig. 1 Kaplan–Meier analysis of Red cell alloantibody development in patients on veno-venous extracorporeal membrane oxygenation
disappear or become weaker. However, development of red cell alloimmunisation has significant implications for further transfusion, and most importantly if the VVECMO was used a bridge to lung transplant. Fortunately, none of the patients who developed RC alloantibodies required transplant in our cohort. It is not practically possible to avoid RC alloimmunisation completely. However, we already take measures to reduce RC transfusion further by optimising haematinics (B12, folate and iron) and keeping systemic anticoagulation as low as possible to avoid bleeding. Studies should be performed to investigate the role of erythropoietin in stimulating red cell production in these critically ill patients, but the risk of thrombosis associated with erythropoietin is a major concern. The lack of a suitable control group is a major limitation of this study. Patients on veno-arterial (VA)-ECMO usually have shorter ECMO duration but a higher number of RC transfusions compared to VV-ECMO. We did not compare the two groups in this study. Therefore, it is not possible to comment on dose (number of RC units) versus duration in patients receiving VV-ECMO versus VA-ECMO. In conclusion, despite the lower Hb threshold for tran
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