The American Journal of Surgery (2008) 196, 62– 63
Clinical Surgery-American
Commentry: Transfusions: weighing the risks and benefits
Mark A. Malangoni, M.D.*
Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center Campus,
Cleveland, OH, USA
KEYWORDS: This commentary identifies important differences in patient groups that affect the observations in the
Transfusion-related accompanying article.
effects; © 2008 Elsevier Inc. All rights reserved.
leukocyte reduction;
red blood cell
transfusion
Red blood cell (RBC) transfusions have been responsible
for saving many lives, particularly in patients suffering from
acute blood loss caused by hemorrhagic shock. Refinements
in the cross-matching of blood and improvements, including
the identification and reduction of transfusion-related viral
infections, have markedly improved the safety of our blood
supply. More recently, RBC transfusions have been re-
ported to have detrimental effects associated with white
blood cells, which are invariably present in the transfused
blood. These effects include an increased risk of cancer
recurrence after resection, febrile nonhemolytic transfusion
reactions, and other immune-mediated effects. Because
white blood cells have been implicated as a potential cause
for these problems, it stands to reason that filtration of
leukocytes to reduce their prevalence would be proposed to
avoid these effects. Whether the risk of infectious compli-
cations is the result of these transfusion-mediated effects is
inconclusive. RBC transfusions have been associated with
the risk of infectious complications after penetrating ab-
dominal injury for ⬎20 years.1 However, transfusions may
be just a more easily quantifiable parameter to assess the
degree of hemorrhagic shock, which is strongly linked to
infection risk.
* Corresponding author. Tel.: ⫹1-216-778-4558; fax: ⫹1-216-778-1099.
E-mail address: mmalangoni@metrohealth.org
Manuscript received November 15, 2007; revised manuscript Novem-
ber 18, 2007
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2007.11.014
Friese et al2 report a retrospective study of injured adults
who received RBC transfusions during two 22-month peri-
ods before and after adoption of a prestorage leukocyte-
reduction policy for RBC transfusions at their institution.
They have previously presented and published that mortal-
ity and hospital length of stay were not affected by the use
of leukocyte-reduced transfusions in these same patients.3
Despite of any lack of effect on mortality, the investigators
performed a posthoc analysis on this same data set, with the
hypothesis that leukocyte-reduced RBC transfusions given
within the first 24 hours after injury would result in a lower
risk of infection. They purport that the change to leukocyte-
reduced RBC transfusions was associated with a reduction
in infectious complications in injured patients.
The many shortcomings of this report minimize the value
of its conclusions. The before-and-after patient groups dif-
fer in important ways. The intervention (“after”) group had
more women, had lower injury severity scores, had reduced
number of ventilator days/patient, and received fewer RBC
transfusions/patient. All of these parameters have been
demonstrated to reduce infection risk, and it is probable that
their cumulative effect decreases risk logarithmically. Ven-
tilator days have particular significance because this mea-
sure is strongly correlated with the incidence of pneumonia
in injured patients and was not corrected for in the regres-
sion analysis. Whether all transfusions are included in the
analysis and why patients who received transfusions after
24 hours were excluded is unclear.
M. A. Malangoni Risks and benefits of transfusion
Importantly, other critical aspects of care—such as rapid
ventilator weaning protocols, emphasis on strict glucose
control, lower threshold for RBC transfusion, and greater
routine use of bronchoalveolar lavage for diagnosis of ven-
tilator-associated pneumonia— changed during the time pe-
riod between the 2 intervals assessed. The investigators do not
address whether these care improvements occurred at their
institution or what impact such change may have had on their
results. These meaningful differences are why prospective,
randomized clinical trials are so important. Concurrent entry of
patients into these 2 treatment arms would minimize other
treatment effects that are invariably present. Likewise,
posthoc analyses have less validity than prospectively de-
termined hypotheses. One could easily conclude that the
results of this study are simply due to differences in care
between the two time intervals rather than to the routine use
of leukocyte-reduced RBC transfusions.
Leukocyte-reduction is expensive. It has some beneficial
effects for patients who are at risk for immune sensitization
63
from leukocyte-associated antigens. In these patients, its
expense may justify the cost. There is a tendency for phy-
sicians to adopt new (and usually more expensive) therapies
without demonstrable benefit. Until the benefit of leuko-
cyte-reduced RBC transfusions on the risk of infectious
complications is more clearly demonstrated, we should
avoid jumping on the bandwagon.
References
1. Nichols RL, Smith JW, Klein DB, et al. Risk of infection after pene-
trating abdominal trauma. N Engl J Med 1984;311:1065–70.
2. Friese RS, Sperry JL, Phelan HA, et al. The use of leukoreduced red cell
products is associated with fewer infectious complications in trauma
patients. Am J Surg 2008; (in press)
3. Phelan HA, Sperry JL, Friese RS. Leukoreduction prior to red blood cell
transfusion has no impact on mortality in trauma patients. J Surg Res
2007;138:32– 6.