Aryeh Shander

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Background: Patient blood management (PBM) strategies have been shown to significantly reduce the use of blood products and enabled surgical procedures to be carried out safely without the need for transfusions. This evidence has raised questions about the possibilities of the “extreme” application of PBM strategies for complex surgical interventions, such as organ transplants, even in patients in whom it is not possible to proceed with transfusion. The aim of this scoping review was to identify and describe the current evidence available in the medical literature on the transplant of the four main solid organs: kidney, heart, liver, and lung in patients declining blood transfusions. Methods: A comprehensive literature search was conducted using PubMed from January 2000 to February 2025. Only articles reporting cases, case series, population samples, or comparative studies describing solid organ transplantation without the use of blood components were included. The results are presented separately for each solid organ. Results: Kidney: Nine studies were included, seven of which reported case reports or case series of kidney or kidney–pancreas transplants, and two articles were comparative studies. Liver: Nine studies reported bloodless liver transplants, eight were case reports or case series, and one was a comparative observational study. Heart: Five studies were included, four of which were case reports of heart transplants; in addition there was a comparative study describing eight heart transplants without the use of blood components to 16 transfusable transplant patients. Lung: Five studies reporting lung transplant without transfusion were reported, four of which were case reports performed in the absence of deaths, and two of which were bilateral. Furthermore, there was an article describing two single lung transplants without the use of blood components compared to ten transfusable transplant patients. Conclusions: The analysis performed demonstrates the possibility, depending on the organ, of performing solid organ transplant procedures without the use of blood components in selected and carefully prepared patients by experienced multidisciplinary teams.

Background: There are no overviews of systematic reviews investigating haemoglobin thresholds for transfusion. This is important as the literature on transfusion thresholds has grown considerably in recent years. Our aim was to synthesise evidence from systematic reviews and meta-analyses of the effects of restrictive and liberal transfusion strategies on mortality. Methods: This was a systematic review of systematic reviews (overview). We searched MEDLINE, Embase, Web of Science Core Collection, PubMed, Google Scholar, and the Joanna Briggs Institute EBP Database, from 2008 to 2018. We included systematic reviews and meta-analyses of randomised controlled trials comparing mortality in patients assigned to red cell transfusion strategies based on haemoglobin thresholds. Two independent reviewers extracted data and assessed methodological quality. We assessed the methodological quality of included reviews using AMSTAR 2 and the quality of evidence pooled using an algorithm to assign GRADE levels. Results: We included 19 systematic reviews reporting 33 meta-analyses of mortality outcomes from 53 unique randomised controlled trials. Of the 33 meta-analyses, one was graded as high quality, 15 were moderate, and 17 were low. Of the meta-analyses presenting high- to moderate-quality evidence, 12 (75.0%) reported no statistically significant difference in mortality between restrictive and liberal transfusion groups and four (25.0%) reported significantly lower mortality for patients assigned to a restrictive transfusion strategy. We found few systematic reviews addressed clinical differences between included studies: variation was observed in haemoglobin threshold concentrations, the absolute between group difference in haemoglobin threshold concentration, time to randomisation (resulting in transfusions administered prior to randomisation), and transfusion dosing regimens. Conclusions: Meta-analyses graded as high to moderate quality indicate that in most patient populations no difference in mortality exists between patients assigned to a restrictive or liberal transfusion strategy. Trial registration: PROSPERO CRD42019120503

BACKGROUND: Hemoglobin‐Based Oxygen Carriers (HBOCs) can act as an “oxygen bridge” in acute severe anemia when transfusion is indicated, but not possible. We present data on 10 Expanded Access (EA) patients treated with high cumulative doses of Hemopure (HBOC‐201), to assess the ability of HBOC‐201 to safely treat life threatening anemia in situations where high volumes of product were administered over an extended period of time.STUDY DESIGN AND METHODS: Inclusion in this study required that the patient receive at least 10 units of HBOC‐201 between 2014 and 2017 under the FDA‐sanctioned EA program. Depending on a patient's geographical location, treatment with HBOC‐201 was obtained through either a single patient emergency Investigational New Drug (IND) application, or an intermediate size population IND. Of the 41 patients who were treated during this period, 10 patients received 10 or more units of the product. Data were obtained from medical records.RESULTS: Treatments with HBOC‐201 started within 24 hours of signing consent and were administered at an average rate of 1.99 (SD 0.17) units per day over a mean of 8.2 days (SD 2.9), during which patients received on average 16.2 units (SD 5.7 units) of HBOC‐201. The median pre‐treatment nadir corpuscular hemoglobin (Hb) concentration was 3.3 (SD 0.9) g/dL and post‐treatment Hemoglobin was 7.3 (SD 1.7) g/dL. Common side effects included methemoglobinemia, gastrointestinal symptoms, and hypertension. However, no product‐related serious adverse events (SAEs) were noted. All patients survived.CONCLUSIONS: Administration of HBOC‐201 over an extended period is a feasible and safe oxygen bridge for severely anemic patients who cannot be transfused with RBC.