The Threshold for Prophylactic Platelet Transfusions in Adults with Acute Myeloid Leukemia
Paolo Rebulla, M.D., Guido Finazzi, M.D., Francesca Marangoni, M.D., Giuseppe Avvisati, M.D., Luigi Gugliotta, M.D., Gianni Tognoni, M.D., Tiziano Barbui, M.D., Franco Mandelli, M.D., Girolamo Sirchia, M.D., for The Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto
Background Prophylactic platelet transfusions are usually administeredto patients receiving myelotoxic chemotherapy when their plateletcount falls below 20,000 per cubic millimeter. Some observationssuggest that lower platelet counts can be appropriate in patientsin stable condition, but the safety of lower thresholds is uncertain.
Methods We evaluated 255 adolescents and adults (age, 16 to70 years) with newly diagnosed acute myeloid leukemia (but notacute promyelocytic leukemia), who were treated in 21 centers.One hundred thirty-five patients were randomly assigned to receivea transfusion when their platelet count fell below 10,000 percubic millimeter (or 10,000 to 20,000 per cubic millimeter inthose with a temperature above 38°C, with active bleeding,or a need for invasive procedures), and 120 patients were assignedto receive a transfusion when their platelet count was lessthan 20,000 per cubic millimeter.
Results Patients in the group with a threshold of 10,000 plateletsper cubic millimeter received 21.5 percent fewer platelet transfusionsthan the patients in the group with a threshold of 20,000 plateletsper cubic millimeter (P = 0.001). The numbers of red-cell unitstransfused were not significantly different between groups.Major bleeding (defined as any bleeding more than petechiaeor mucosal or retinal bleeding) occurred in 21.5 and 20 percentof patients, respectively (P = 0.41), and on 3.1 and 2.0 percentof the days of hospitalization. One episode of fatal cerebralhemorrhage occurred in the group with a threshold of 10,000platelets per cubic millimeter; none occurred in the other group(P = 0.95). Actuarial estimates of survival during inductionchemotherapy, actuarial estimates of the absence of major bleeding,and the length of hospital stay were not significantly differentin the two groups.
Conclusions The risk of major bleeding during induction chemotherapyin adolescents and adults with acute myeloid leukemia (exceptacute promyelocytic leukemia, which we did not study) was similarwith platelet-transfusion thresholds of 20,000 per cubic millimeterand 10,000 per cubic millimeter (or 10,000 to 20,000 per cubicmillimeter when body temperature exceeded 38°C, there wasactive bleeding, or invasive procedures were needed). Use ofthe lower threshold reduced platelet use by 21.5 percent.
Source Information
From the Centro Trasfusionale e di Immunologia dei Trapianti, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore, Milan (P.R., F. Marangoni, G.S.); Divisione di Ematologia, Ospedali Riuniti, Bergamo (G.F., T.B.); Dipartimento di Biotecnologie Cellulari ed Ematologia, Università La Sapienza, Rome (G.A., F. Mandelli); Istituto di Ematologia e Oncologia Medica L. e A. Seràgnoli, Policlinico S. Orsola, Bologna (L.G.); and Istituto di Ricerche Farmacologiche Mario Negri, Milan (G.T.) — all in Italy.
Address reprint requests to Dr. Paolo Rebulla at the Centro Trasfusionale e di Immunologia dei Trapianti, Ospedale Maggiore, via F. Sforza 35, 20122 Milan, Italy.
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