Phase II trial of standard versus increased
transfusion volume in Ugandan children with
acute severe anemia
Olupot-Olupot et al.
Olupot-Olupot et al. BMC Medicine 2014, 12:67
http://www.biomedcentral.com/1741-7015/12/67
Olupot-Olupot et al. BMC Medicine 2014, 12:67
http://www.biomedcentral.com/1741-7015/12/67
Medicine for Global Health
RESEARCH ARTICLE
Open Access
Phase II trial of standard versus increased
transfusion volume in Ugandan children with
acute severe anemia
Peter Olupot-Olupot1, Charles Engoru2, Jennifer Thompson3, Julius Nteziyaremye3, Martin Chebet1,
Tonny Ssenyondo1, Cornelius M Dambisya1, Vicent Okuuny2, Ronald Wokulira2, Denis Amorut2, Paul Ongodia1,
Ayub Mpoya4, Thomas N Williams4,5, Sophie Uyoga4, Alex Macharia4, Diana M Gibb3, A Sarah Walker3
and Kathryn Maitland4,5*
Abstract
Background: Severe anemia (SA, hemoglobin <6 g/dl) is a leading cause of pediatric hospital admission in Africa,
with significant in-hospital mortality. The underlying etiology is often infectious, but specific pathogens are rarely
identified. Guidelines developed to encourage rational blood use recommend a standard volume of whole blood
(20 ml/kg) for transfusion, but this is commonly associated with a frequent need for repeat transfusion and poor
outcome. Evidence is lacking on what hemoglobin threshold criteria for intervention and volume are associated
with the optimal survival outcomes.
Methods: We evaluated the safety and efficacy of a higher volume of whole blood (30 ml/kg; Tx30: n = 78) against
the standard volume (20 ml/kg; Tx20: n = 82) in Ugandan children (median age 36 months (interquartile range
(IQR) 13 to 53)) for 24-hour anemia correction (hemoglobin >6 g/dl: primary outcome) and 28-day survival.
Results: Median admission hemoglobin was 4.2 g/dl (IQR 3.1 to 4.9). Initial volume received followed the
randomization strategy in 155 (97%) patients. By 24-hours, 70 (90%) children in the Tx30 arm had corrected SA
compared to 61 (74%) in the Tx20 arm; cause-specific hazard ratio = 1.54 (95% confidence interval 1.09 to 2.18, P = 0.01).
From admission to day 28 there was a greater hemoglobin increase from enrollment in Tx30 (global P <0.0001).
Serious adverse events included one non-fatal allergic reaction and one death in the Tx30 arm. There were six
deaths in the Tx20 arm (P = 0.12); three deaths were adjudicated as possibly related to transfusion, but none
secondary to volume overload.
Conclusion: A higher initial transfusion volume prescribed at hospital admission was safe and resulted in an
accelerated hematological recovery in Ugandan children with SA. Future testing in a large, pragmatic clinical
trial to establish the effect on short and longer-term survival is warranted.
Please see related commentary article http://www.biomedcentral.com/1741-7015/12/68/abstract.
Trial registration: ClinicalTrials.Gov identifier: NCT01461590 registered 26 October 2011.
Keywords: Transfusion, Severe anemia, African children, Clinical trial, Infectious disease
* Correspondence: k.maitland@imperial.ac.uk
4
Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, PO
Box 230, Kilifi, Kenya
5
Wellcome Trust Centre for Clinical Tropical Medicine, Department of
Paediatrics, Faculty of Medicine, St Marys Campus, Norfolk Place, Imperial
College, London W2 1PG, UK
Full list of author information is available at the end of the article
© 2014 Olupot-Olupot et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
Olupot-Olupot et al. BMC Medicine 2014, 12:67
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Background
In sub-Saharan Africa severe anemia in children, defined
as a hemoglobin less than either 5 g/dl or 6 g/dl, remains
a leading cause of hospital admission [1] and a major
factor in the 800,000 malaria deaths/year [2]. Young children and women account for more than three quarters of
the blood transfusions in sub-Saharan Africa - most given
as emergency life-saving treatments [3]. Despite high
demand, blood supply is inadequate to meet the needs.
On average only 2.3 units of blood are donated per
1,000 population in sub Saharan Africa, compared with
8.1 and 36.7 in medium and high-income countries [4].
Furthermore, most nationally funded blood services
depend almost entirely on whole blood for transfusion,
since the model of exclusive component preparation
has technical, financial and possibly serious negative
consequences and can only be feasibly implemented if
substantially supported by external aid [3].
Owing to these resource-limitations, guidelines have
been developed by the World Health Organization (WHO)
that encourage the rational use of blood transfusion to
treat severe anemia in order to prevent overuse and to
reduce the risk of transfusion-transmitted infection
[5,6]. Nevertheless, evidence is lacking regarding which
hemoglobin threshold criteria, volume and timing of
transfusion intervention are associated with optimal
survival outcomes. Consequently adherence to the current
guidelines is poor [7,8]. Children with severe anemia have
high rates of in-hospital mortality (9% to 10%) [9], suggesting that the current recommendations are not optimal.
An inadequate supply of blood to treat emergencies has
previously been highlighted as a key factor driving poor
outcomes, with 63% of the early deaths (<6 hours) occurring while awaiting transfusion [10]. A further consideration is whether the volume of transfusion is sufficient
to correct the anemia. Currently, WHO recommends
20 ml/kg of whole blood (or 10 ml/kg packed cells) for all
levels of anemia <4 g/dl, irrespective of initial hemoglobin
or <6 g/dl if complicated by life-threatening features [5].
Few data are available on volumes received. One prospective study of pediatric transfusions in Siaya, Kenya, reported
the mean volume of transfusion as 25 to 26 ml/kg whole
blood [7]; however, 14% of transfusions were <15 ml/kg.
Others following WHO guidelines (20 ml/kg) have shown
only a modest hemoglobin rise of mean 2.5 to 3.3 g/dl
[10-12] with approximately 25% remaining severely anemic
(<5 g/dL) [10] following initial transfusion. Unpublished
data from the Fluid Expansion as Supportive Therapy
(FEAST) trial [13] indicates that of 1,422 children transfused, 322 (23%) received two or more transfusions, the
proportion being greater (212/612, 35%) in those with
hemoglobin <4 g/dl at enrollment. Multiple transfusions
not only incur additional resource utilization but expose
children to added risks of infection, transfusion reaction
Page 2 of 11
and adverse events. Using standard formulae to calculate the volume required [14], the current doses prescribed under-treat children with profound anemia by
nearly 30% [15].
Larger initial transfusion volumes have not been systematically evaluated. We therefore investigated whether a
greater initial volume of whole blood (30 ml/kg) compared
to the standard recommendation (20 ml/kg whole blood)
safely treated severe anemia with respect to a superior
hematological correction and reduced the need for
extra transfusions.
Methods
Design and treatment protocol
We conducted a multicenter open randomized Phase
II trial, with the aim of providing preliminary results
regarding the safety of higher volume transfusions and their
feasibility and acceptability to clinicians and transfusion services. Eligible children from two clinical centers in Eastern
Uganda (Mbale and Soroti Regional Referral Hospitals)
were randomly assigned on admission to hospital (ratio 1:1)
to receive either: (1) 20 ml/kg whole blood transfusion
(Tx20) (alternatively 10 ml/kg of packed red blood cells
(standard of care)); or (2) 30 ml/kg whole blood transfusion
(Tx30) (or 15 ml/kg packed red blood cells). Sites were
instructed to transfuse blood over three to four hours,
as recommended by WHO.
Study population
Screening procedure
We aimed to enroll 160 children, >60-days- and <12-yearsold, with severe anemia at admission to the pediatric ward.
Dedicated trial clinicians and nurses were employed to
conduct the study. Potentially eligible children with clinical
evidence of pallor were identified and registered in the
eligibility screening log. A rapid bedside test by HemOcue
(Ängelholm, Sweden) and bedside examination determined
hemoglobin level and severity. Children were eligible if
they had severe anemia (hemoglobin <6 g/dl) at the time
of admission to hospital), no previous transfusion during
the course of the current illness and a guardian or parent
willing/able to provide consent (Figure 1: Trial Flow).
Complicated severe anemia was defined as children
with hemoglobin 4 to 6 g/dl in conjunction with markers
of clinical severity (reduced conscious level or respiratory
distress) or profound anemia (hemoglobin <4 g/dl).
Children with malignancy, surgery, acute trauma or acute
severe malnutrition were excluded from the study.
Outcome measures
The primary outcome was correction of severe anemia
(to hemoglobin >6 g/dl) at 24 hours. Secondary outcomes
included: (1) meeting criteria for additional transfusion
(development of profound anemia (hemoglobin <4 g/dl)
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the illness a provision was approved for verbal assent from
a legal surrogate followed by delayed informed consent as
soon as practicable.
The Mbale Research Ethics Committee, Mbale, Uganda
approved the protocol. The trial was registered, prior to
enrollment, with ClinicalTrials.Gov identifer: NCT01461590
(registered 26 October 2011).
207 children were
screened for eligibility
45 were excluded for not
meeting entry criteria:
41 had Hb>6g/dl
1 had an active bleed
3 had previous transfusions
in the illness
2 declined to participate
Randomization
160 children were
enrolled
82 were randomly
assigned to Arm A:
20mls/kg
78 were randomly
assigned to Arm B:
30mls/kg
82 were included in
analysis
78 were included in
analysis
Follow up to 28 days:
70 Survived (with Hb
assessment)
6 Survived (but no Hb
assessment)
6 Died before discharge
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Follow up to 28 days:
71 Survived (with Hb
assessment)
6 Survived (but no Hb
assessment)
1 Died between
discharge and 28 days
Figure 1 Trial flow.
or hemoglobin 4 to 6 g/dl with new markers of severity
(impaired consciousness or respiratory distress)) from eight
hours post randomization; (2) serious adverse events
defined according to Good Clinical Practice [16] and
including suspected pulmonary edema (bilateral basal
crepitations with hypoxemia (oxygen saturations <90%);
biventricular heart failure (severe tachycardia (<12-monthsold: >180 beats per minute (bpm); 12-months to 5-yearsold: >160 bpm; >5-years-old: >140 bpm) plus an increasing
liver size) or suspected transfusion reaction; (3) mortality
through 48 hours and 28 days post-admission; and (4)
redevelopment of severe anemia (hemoglobin <6 g/dl)
or mortality at 28 days post-admission.
Study procedures
Consent
Prospective written, informed consent was obtained from
parents or guardians of the children. The information sheet
was in their usual language and was read aloud to those unable to read. Parents and guardians were encouraged to ask
questions about the trial prior to signing the consent form.
In cases where prior written consent from parents or
guardians could not be obtained because of severity of
Randomization was stratified by clinical center. The
treatment allocation (Tx30 or Tx20) was kept in numbered, sealed opaque envelopes, each signed across the
seal. The cards were numbered consecutively and opened
in numerical order. The randomization list and envelopes
were prepared before the trial by a statistician at the Kilifi
Clinical Trials Facility and the list was not available to
the investigators.
Sample size
The study aimed to generate pilot safety and efficacy data
on a higher transfusion volume (30 ml/kg) in children with
severe anemia. Numbers required to address the trial
objectives were therefore balanced against exposing
children to a therapeutic intervention (dose) for which
there are limited data. The overall sample size of 160
children (approximately 80 having signs of severity as
defined above) randomized to 20 versus 30 ml/kg provided at least 80% power to detect major (20% to 25%)
increases in the proportions experiencing the primary
and secondary outcomes.
Clinical monitoring and study assessments
Following consent and randomization, lactate (LactatePro®),
glucose, malaria status (by blood film and Optimal® rapid
diagnostic test (RDT)) and cross match were performed.
Following national guidelines, HIV testing was conducted
after completion of admission procedures, with pre- and
post-test counseling done in accordance with routine practice. Blood was collected at admission into ethylenediaminetetraacetic acid (EDTA), stored at -80°C and typed by
PCR for the hemoglobinopathies sickle cell anemia (HbSS),
sickle cell trait (HbAS) and the common African variant
of α-thalassemia and for the red cell enzymopathy G6PD
deficiency at the end of the study, as described in detail
previously [17], using DNA extracted using Qiagen DNA
blood mini kits (Qiagen, Crawley, UK).
Transfusions were given in standard infusion sets
incorporating a graded, filtered burette. Since the volume of the burette was only 150 ml, each transfusion,
depending on volume, was given as consecutive aliquots (150 ml maximum/aliquot) until the transfusion
was complete. For analysis, a separate transfusion was
defined by a gap of 30 minutes or more between consecutive aliquots.
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All children were reassessed at 30 minutes, 1 hour, 90
minutes, and 2, 4, 8, 16, 24 and 48 hours for consciousness
level, vital signs (heart rate, oxygen saturation, respiratory
rate, axillary temperature, blood pressure) and for adverse
events. Hemoglobin was monitored 8-hourly on the day of
admission and daily thereafter. Glucose and lactate were
reassessed at 8, 16 and 24 hours, with lactate assessed again
at 48 hours. At follow up (day 28) hemoglobin and malaria
parasite status were reassessed.
Serious adverse event reports were sent to the Clinical
Trials Facility, Kilifi, Kenya within two days and were
also monitored against source documents by visiting
monitors. An independent clinician removed all references
to the randomized arm prior to review by the Endpoint
Review Committee (ERC), which included an independent
chair (JE), one independent clinician (IB), one clinician involved in trial management but not patient enrollment
(KM) and one clinician not involved in the day-to-day
running of the trial (DMG). The ERC had access to clinical narratives, bedside vital observations, serial laboratory
and bedside blood tests and concomitant treatments. They
adjudicated (blind to randomized arm) on whether fatal
and non-fatal events could be related to transfusion or the
volume transfused, and the main cause of death.
Further management
An additional transfusion was permitted after eight hours
(at the time of the first protocol hemoglobin reassessment)
for children who still had either (1) hemoglobin <4 g/dl
or (2) hemoglobin 4 to 6 g/dl and a sign of severity
(respiratory distress or impaired consciousness). If a
child required maintenance fluids, 5% dextrose was given at
3 to 4 ml/kg per hour until the child was able to drink. All
children received standard treatments recommended by
national guidelines, depending on their illness, including
parenteral anti-malarials, antibiotics and/or antipyretics,
anticonvulsants, oxygen (for oxygen saturations <90%)
and glucose for hypoglycemia. Use of diuretics during
blood transfusion was discouraged and reserved for
children developing new signs suggestive of pulmonary
edema or biventricular heart failure (defined as respiratory
distress plus oxygen saturation <90%, bilateral basal
crepitations, severe tachycardia and increasing liver
size following transfusion).
Statistical analysis
All analyses followed intention-to-treat and all statistical
tests were two-sided. For the primary endpoint (correction
of severe anemia at 24 hours), the arms were compared using Cox proportional hazards regression for
the cause-specific hazard of a hemoglobin >6 g/dl before death, and the relative difference estimated by
cause-specific hazard ratios. The cumulative incidence of
severe anemia before death was also estimated; comparison
Page 4 of 11
of the sub-distribution hazard corresponding to the
cumulative incidence between arms [18] gave similar
results to the cause-specific hazards (not shown). Secondary outcomes were compared between arms using
risk ratios and Fisher’s exact test. Other continuous
characteristics (for example, volume and rates of the
initial transfusion) were compared between arms using
two sample t-tests assuming equal variance in the arms;
categorical characteristics (for example, number of transfusions per child) were compared between arms using Fisher’s
exact test. Change in vital signs, hemoglobin, glucose
and lactate from baseline were compared between the
arms using two sample t-tests at scheduled assessments
assuming equal variance in the arms, and across all time
points (global tests of difference) using generalized estimating equations (normal distribution, independent
correlation structure).
Results
Study patients
Overall, 160 children were randomized between 10 October
2011 and 12 January 2012 (82 to Tx20, 78 to Tx30). All
children included in the trial met eligibility criteria
(Figure 1). Most baseline characteristics were broadly
balanced between the arms (Table 1), although there
were a few moderate differences as expected given the
relatively small sample size. Median age was 36 months
(interquartile range (IQR) 13 to 53). Signs of severity
(respiratory distress or impaired consciousness) were
present in 53% and 33% children, respectively. A total of
59% of the children had either a positive malaria slide
and/or malaria RDT; median hemoglobin was 4.2 g/dl
(IQR 3.1 to 4.9) with 46% having profound anemia (<4 g/dl);
31% had severe lactic acidosis (≥5 mmol/L). Twenty percent
of participants had sickle cell anemia (HbSS), an observation
consistent with this disease being a major risk factor for
admission with severe anemia [19,20]. Conversely, sickle cell
trait (HbAS), heterozygous and homozygous α-thalassemia
and G6PD deficiency were found in lower frequencies than
in the background population (unpublished observations),
consistent with previous observations that these traits are
associated with host protection from severe malaria [21-23].
Transfusions administered
All children received a transfusion and the initial volume
actually infused followed the randomization strategy
(within 5 ml/kg) in 80 (98%) patients in the Tx20 arm
and in 75 (96%) in the Tx30 study arm. In the Tx20 arm,
one child died before the transfusion was completed preventing them from receiving the full amount of blood,
the other inadvertently received an initial transfusion of
30 ml/kg whole blood. In the Tx30 arm all three children
not following the randomization strategy received less than
25 ml/kg in the initial transfusion, and two subsequently
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Table 1 Baseline characteristics
Arm A: Tx20
20 ml/kg
Arm B: Tx30
30 ml/kg
Total
(Number = 82)
(Number = 78)
(Number = 160)
Age months median (IQR)
36 (19 to 54)
31 (11 to 48)
36 (13 to 53)
Female sex – n/ total n (%)
Variable
Demographic and anthropometric characteristics
41/82 (50)
40/77 (52)
81/159 (51)
Mid-upper arm Circumference ≤11.5 cm – n/total n (%)
1/80 (1)
3/78 (4)
4/158 (3)
Weight kg - median (IQR)
13 (9-16)
11 (8-15)
12 (9-15)
39/81 (48)
37/78 (47)
76/159 (48)
Findings at presentation
Axillary temperature
>37.5°C – n/total n (%)
<36°C (Hypothermia) – n/total n (%)
3/81 (4)
4/78 (5)
7/159 (4)
Oxygen saturation <90% - n/total n (%)
9/78 (12)
9/78 (12)
18/156 (12)
Moderate hypotension - n (%)
5 (6)
6 (8)
11 (7)
Dehydration - n (%)
6 (7)
6 (8)
12 (8)
81 (99)
76 (97)
157 (98)
Severe pallor (lips, gums, or inner eyelids) - n (%)
Consciousness level – n (%)
Total n
81
78
159
Alert
51 (63)
56 (72)
107 (67)
Prostration
29 (36)
20 (26)
49 (31)
1 (1)
2 (3)
3 (2)
Coma
Convulsions during this illness - n (%)
6 (7)
13 (17)
19 (12)
Hemoglobinuria (dark urine) - n (%)
29 (35)
26 (33)
55 (34)
Jaundice visible to clinician - n (%)
43 (52)
44 (56)
87 (54)
mean ± sd
47 ± 15
47 ± 13
47 ± 14
respiratory distress – n (%)
41 (50)
43 (55)
84 (53)
153 (136 to 173)
156 (142 to 168)
155 (139 to 170)
Respiratory rate breaths/minute
Heart rate beats/minute
median (IQR)
Bradycardia (<80) - n (%)
1 (1)
0 (0)
1(1)
30 (37)
26 (33)
56 (35)
32/82 (39)
25/77 (32)
57/159 (36)
4.2 (3.0 to 4.8)
4.3 (3.3 to 4.9)
4.2 (3.1 to 4.9)
37 (45)
36 (46)
73 (46)
<2.5 mmol/liter (45 mg/dl)
2/82 (2)
0/75 (0)
2/157 (1)
<3.0 mmol/liter (54 mg/dl)
2/82 (2)
0/75 (0)
2/157 (1)
23/82 (28)
26/76 (34)
49/158 (31)
1/39 (3)
0/38 (0)
1/77 (1)
Negative on all tests done
33 (40)
32 (41)
65(41)
RDT positive, slide negative/unknown
13 (16)
15 (19)
28 (18)
Severe tachycardia - n (%)a
Hepatomegaly – n/total n (%)
Laboratory assessment
Hemoglobin - n (%)
Median (IQR)
<4 g/dl
Glucose – n/ total n (%)
Lactate ≥5 mmol/liter – n/total n (%)
Positive for HIV antibody - n/ total n (%)
Positive for malaria parasitemia - n (%)
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Table 1 Baseline characteristics (Continued)
RDT negative/unknown, slide positive
4 (5)
3 (4)
7 (4)
32 (39)
28 (36)
60 (38)
63 (77)
57 (73)
120 (75)
2 (2)
6 (8)
8 (5)
17 (21)
15 (19)
32 (20)
Normal
45 (60)
48 (65)
93 (62)
Heterozygote
24 (32)
24 (32)
48 (32)
Homozygote
6 (8)
2 (3)
8 (5)
Normal
56 (77)
55 (79)
111 (78)
Heterozygote/Hemizygoteb
8 (11)
7 (10)
15 (10)
Homozygote
9 (12)
8 (11)
17 (12)
RDT positive, slide positive
Genotypes
Sickle cell– n (%)
AA (normal)
AS (sickle cell trait)
SS (sickle cell anemia)
Alpha thalassemia – n (%)
G6PD deficiency – n (%)
Note: denominators are all children randomized unless otherwise shown; adefined as heart rate (HR) >180 for <1 year old, HR >160 for <5 years old, HR >140 for
more than 5 years old; bfemale heterozygote/male hemizygote. IQR, interquartile range; n, number; RDT, rapid diagnostic test; sd, standard deviation.
received additional transfusions. All initial transfusions
were whole blood rather than packed cells. There was
only one prescription of packed cells in the whole trial,
given as a second transfusion (Tx30 arm). Median initial
transfusion volumes were 20 ml/kg (IQR 20 to 20) and
30 ml/kg (IQR 30 to 30) in the respective arms (Table 2).
Time to initial transfusion was similar between the two
arms (P = 0.74), and was 98 minutes (IQR 75 to 128)
overall, but transfusions were given signficantly faster in
the Tx30 arm than in the Tx20 arm (median 7.6 versus
5.7 ml/kg/hour, respectively, P <0.0001). During the first
48 hours, 69 (88%) children assigned to Tx30 received
only one transfusion; an additional eight and one patients
received two or three transfusions, respectively. In Tx20, 67
(82%) children received only one transfusion and fifteen
(18%) received two or more transfusions. These differences
were not statistically significant (P = 0.23). Two patients in
Tx20 and one patient in Tx30 received another transfusion
after 48 hours.
Outcomes
By 24 hours after transfusion significantly more children in the Tx30 arm had corrected their severe anemia
(primary endpoint) 70 (90%) versus 61 (74%) in the Tx20
arm; cause-specific hazard ratio for anemia correction
before death = 1.54 (95% confidence interval (CI) 1.09 to
2.18, P = 0.01) (Table 3; Figure 2). There was also a trend
towards more children in Tx20 than in Tx30 meeting
the study criteria for additional transfusion (P = 0.06).
Although more children in Tx20 had serious adverse
Table 2 Volume, timing and additional transfusion by study arm
Arm A: 20 ml/kg (Number = 82)
a
Arm B: 30 ml/kg (Number = 78)
P value
Volume of initial transfusion (ml/kg) – median (IQR)
20 (20 to 20)
30 (30 to 30)
<0.0001
Rate of initial transfusiona (ml/kg/hr) – median (IQR)
5.7 (4.9 to 6.7)
7.6 (6.1 to 8.4)
<0.0001
Time to initial transfusion (minutes) – median (IQR)
95 (75 to 128)
103 (75 to 130)
0.74
Total volume tranfused 0 to 48 hours (ml/kg) – median (IQR)
20 (20 to 20)
30 (30 to 30)
<0.0001
1
67 (82)
69 (88)
2
14 (17)
8 (10)
3
0 (0)
1 (1)
4
1 (1)
0(0)
2
1
Number of transfusionsb per child 0 to 48 hours, number (%)
Number of children with a transfusion after 48 hours
a
0.23
Refers to blood infused before the first 30-minute break between aliquots of blood. This was the entire initial prescription for all but three children (all 30 ml/kg arm)
where the last aliquot was given 49, 64, and 92 minutes after the previous aliquot; brefers to the number of prescriptions. IQR, interquartile range.
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Table 3 Primary and secondary endpoints
End point
Arm A: 20 ml/kg
(N = 82)
Arm B: 30 ml/kg
(N = 78)
Risk ratio
(95% CI)
P value
Time to correction of severe anemia (by 24 hours) - number (%)
61 (74)
70 (90)
1.54a (1.09,2.18)
0.01
Children meeting the criteria for additional transfusion - number (%)
12 (15)
4(5)
0.35 (0.12, 1.04)
0.06
SAE – number (%)
6 (7)
2 (3)
0.35 (0.07, 1.68)
0.28
Died before 48 hours – number (%)
4 (5)
0 (0)
Died before 28 days post-admission – number (%)
6 (7)
1 (1)
0.18 (0.02, 1.42)
0.12
9/76 (12)
4/72 (6)
0.47 (0.15, 1.46)
0.25
b
Severe anemia or mortality at 28 days – number/total n (%)
0.12
a
cause specific hazard ratio for correction of severe anemia before death (results similar using competing risks sub-distribution hazard, not shown); bdenominator
excludes children who were alive at 28 days but in whom hemoglobin was not measured. CI, confidence interval; SAE, serious adverse event.
events, differences were consistent with chance (P = 0.28,
Table 3). By 28 days after transfusion, six children (7%) in
Tx20 had died compared to one in Tx30 (P = 0.12; Table 3).
There was also evidence for greater hemoglobin increases
from enrollment in Tx30 versus Tx20 through to 28 days
(global P <0.0001; Figure 3a) and faster reductions in lactate
over the first 24 hours in Tx30 (global P = 0.02; Figure 3b).
There was no evidence of differences in glucose between
the two arms in the first 24 hours (global P = 0.09,
Additional file 1: Figure S1). Differences in hemoglobin
between the arms attenuated through follow-up, with
the mean difference of 0.22 (95% CI -0.59 to 1.03) at
day 28 not reaching statistical significance (P = 0.59).
Although the combined endpoint of re-development of
severe anemia or death at 28 days following admission
also favored the arm receiving 30 ml/kg (4/72 (6%)
compared to those in the standard of care (20 ml/kg) arm,
9/76 (12%)), the difference was not significant (P = 0.25).
In total, eleven children did not attend the 28-day follow
up; all (six Tx20, five Tx30) were traced in the community
and survival status confirmed in ten (six Tx20, four Tx30).
The last child (Tx30) was found to have died four days
after discharge (included as a fatality below). There was no
evidence of a difference between the arms in improvements
in respiratory rate, heart rate or systolic blood pressure
(global P >0.3). From admission to eight hours children in
the Tx30 arm had a slightly (<2%) greater improvement in
oxygen saturation: from eight hours oxygen saturation was
similar in the two arms (global P = 0.003).
Serious adverse events
The independent ERC reviewed all serious adverse
events (SAEs). There was one non-fatal SAE (transfusion
reaction, Tx30) and seven fatal SAEs (Table 4). Six fatal
events occurred in Tx20, all within hospital. Two of the fatalities had evidence of malaria infection. One fatal event
occurred in Tx30, four days following discharge. None of
the fatal events were judged by either the clinician or the
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0
2
4
6
8
10
12
14
16
Hours from admission
Arm A: 20mls/kg
18
20
22
24
Arm B: 30mls/kg
Figure 2 Correction of severe anemia by 24 hours by study arm. Time to first hemoglobin>6mg/dl by study arm by study arm (primary
outcome- correction of severe anemia).
Olupot-Olupot et al. BMC Medicine 2014, 12:67
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Page 8 of 11
a
10
8
6
4
2
0
8hr 16hr 24hr
48hr
Time from Admission
Arm A: 20mls/kg
Time:
N Arm A:20mls/kg
N Arm B:30mls/kg
P
0hrs
82
78
8hrs
73
75
<0.0001
28days
Arm B: 30mls/kg
16hrs
76
76
<0.0001
24hrs
77
74
0.008
48hrs
76
74
0.002
28days
70
71
0.59
Global test of difference between the arms in change in haemoglobin from admission
through to 28 days: p<0.0001
b6
5
4
3
2
0
8hr
16hr
Time from Admission
Arm A: 20mls/kg
24hr
Arm B: 30mls/kg
Time:
0hrs
8hrs
16hrs
24hrs
N Arm A:20 mls/kg
82
73
77
75
N Arm B:30mls/kg
76
73
75
73
P=
0.17
0.04
0.22
Global test of difference between the arms in change in lactate from admission through to
24 hours: p=0.02
Figure 3 Change in mean hemoglobin (3a) and lactate (3b) over follow up by study arm. a. Hemoglobin over 28 days. b. Lactate levels
over 24 hours.
ERC to be due to volume overload: in all fatal SAEs there
was no indication of pulmonary edema, biventricular heart
failure or transfusion-related acute lung injury. Fatal events
were judged to be related to the severity of the underlying
disease in three of six inpatient cases rather than to the
transfusion, and possibly related to transfusion in three
of six inpatient cases (all Tx20). The seventh fatality,
which occured four days after discharge was judged unrelated to transfusion or transfusion volume. In fatal SAEs
occurring in-hospital, transfusions occurred over 2.5 to
6.5 hours, and 6.8 hours in the child dying twelve days
following admission and five days post-discharge from
hospital (see Additional file 2: Table S1 for clinical details).
Discussion
We evaluated the safety and efficacy of a higher volume of
initial transfusion (30 ml/kg) than currently recommended
(20 ml/kg) in a controlled trial in 160 children presenting
to two hospitals in Eastern Uganda with severe anemia
with respect to hematological recovery, mortality, adverse
events and the need for additional transfusion. More than
half of the children had a febrile illness, 60% had evidence
of current or recent Plasmodium falciparum malaria, and
50% and 30% had respiratory distress and/or severe lactic
acidosis, respectively. Seven (4%) children died before 28
days following admission; six fatalities occurred prior to
discharge. Children randomized to 30 ml/kg (Tx30) had a
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Page 9 of 11
Table 4 Serious adverse events (including fatal events)
SAE
Arm A: 20 ml/kg Arm B: 30 ml/kg Total
(Number = 82)
(Number = 78)
Clinician defined SAEs
0
1a
1
Cardio respiratory arrest
1
0
1
Respiratory arrest
1
0
1
Multiple organ failure
0
1b
1
Allergic reaction/transfusion
reaction
Deaths
Other deaths
4
0
4
6
2
8
Definitely
0
-
Probably
0
-
Possibly
3
-
Not related
3
1b
unknown
0
-
Total
Adjudication by endpoint
committee
Fatal events relationship
to transfusionc
a
Median rate of transfusion at the time of reaction, 0.95 ml/minute, no events
judged to have any relationship to volume of transfusions; boccurred four days
after discharge (day 12 post-admission); csee Table S1 in Additional file 2 for
further details of the deaths.
superior hemoglobin recovery at 24 hours (the primary
outcome) and through to 28 days (global P <0.0001);
the observed data suggest that the number of children
meeting the criteria for repeated transfusion was lower
(5% versus 15%, P = 0.06) and there was no indication
that the higher initial volume resulted in an increase in
adverse or fatal events compared to those in the Tx20
arm. The combined endpoint of re-development of severe anemia and survival at 28 days following admission
also favored the arm receiving 30 ml/kg, but the fact
that this was designed as a pilot safety trial meant that it
was not powered to detect differences of this magnitude
and did not reach statistical significance (P = 0.25).
Of the eight adverse events adjudicated by the ERC,
one was probably or definitely related to transfusion
(non-fatal allergic reaction); the others were seven fatalities that either occurred in hospital and were unrelated
(four) or possibly-related (three) to transfusion, or occurred
four days after discharge.
This is the first trial to examine a higher initial volume of
blood transfusion for treatment of severe life-threatening
anemia in African children. Enrollment in the trial was
pragmatic, with few exclusion criteria, at the point of
admission to hospital. Most transfusions were started
within 75 to 130 minutes of enrollment, indicating an
efficient transfusion service, which may have underpinned
the low aggregate in-hospital mortality (4%) that is much
lower than published case-series and prospective studies
in comparable study populations in Africa [10,11]. Children
were managed in busy emergency rooms and pediatric
wards. Children received an additional standard bundle of
care, suggesting that implementation of such bundles, as
well as urgent transfusion, could have also contributed to
lower early mortality than in most of sub-Saharan Africa.
Only one transfusion used packed cells rather than
whole blood. The absence of adverse events related to
volume overload provides reassuring endorsement of
the relative safety of whole blood for pediatric transfusions
in severely ill African children. Our study challenges
the strong United States President’s Emergency Plan
for AIDS Relief (PEPFAR) recommendation (made on
the basis of patient safety) for component preparation,
including packed cells [3]. It also supports the recent
questions around implementation of these specific PEPFAR
requirements for transfusion services, which are both costly
and not evidence-based.
The trial was conducted at two hospitals in Eastern
Uganda, in an area of intense all-year malaria transmission
and where severe anemia as a cause of hospital admission
is a major public health problem. Despite this, only 60% of
the participants in the trial had evidence of malaria; and
four of the six inpatient fatalities were in children with
non-malarial febrile illnesses, indicating that the study
has external validity for pragmatic management of children
with severe anemia, including anemia with a non-malaria
etiology. The study findings remain pertinent since, in
many places, malaria has remained at the same or increased
levels [24] and thus severe anemia remains a major cause
of hospitalization in sub-Saharan Africa. The high frequency of children with sickle cell anemia has been
noted previously in other hospital studies of severe anemia
in malaria-endemic Africa [19]. The imbalance of the proportions with convulsion at admission most likely occurred
due to chance (since the randomization was masked) and
can occur in trials involving small numbers. Since convulsions are a risk factor for poor outcome we do not believe
that these resulted in a lower mortality in the Tx30 arm
[25]. Similarly, the higher in-hospital fatality rate in the
20 ml/kg transfusion arm (representing standard of care)
was also consistent with chance, owing to the small size
of the trial. Of note, virtually all transfusions in the trial
were whole blood rather than packed cells, reflecting
the difficulties local transfusion services have in preparing
packed cells [3], and general lack of availability in populations similar to those studied here.
Conclusions
This trial primarily demonstrated that a higher initial
volume of transfusion (30 ml/kg) could be feasibly and
safely implemented resulting in improvements in early
hematological correction and global outcome, but also
Olupot-Olupot et al. BMC Medicine 2014, 12:67
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suggested a reduced need for repeat transfusion prescription compared to the usual standard of care (20 ml/kg)
recommended by WHO guidelines. Since the WHO
transfusion guidelines have not been systematically
evaluated, this has resulted in variation in practice across
African countries. Incomplete hematological response
in children with severe anemia may underpin the poor
outcomes including relapse, readmission [26] and death
[9,26]. A policy to increase initial transfusion volume
may also result in substantial cost savings, averting the
overuse of scarce resources and decreasing the safety
risk of further transfusion to the child; however, this cannot
be recommended as the standard of care until tested in a
larger trial. Further evaluation in a definitive randomized
controlled trial examining efficacy and cost-effectiveness is
therefore warranted.
Key points
To address the poor outcomes of African children hospitalized with severe anemia we examined a higher initial transfusion volume than is currently recommended
demonstrating its safety and a superior global outcome
at 24 hours and 28 days after admission in Ugandan
children with severe anemia.
Additional files
Additional file 1: Figure S1. Glucose level over 24 hours. Figure S2.
Heart rate over 48 hours. Figure S3. Respiratory rate over 48 hours.
Figure S4. Systolic blood pressure over 48 hours. Figure S5. Oxygen
saturation over 48 hours.
Additional file 2: Table S1. Adjudication of serious adverse events and
deaths by endpoint review committee: clinical narratives. Table S2.
Assignment of causality.
Competing interests
All authors declare they have no conflicts of interest.
Authors’ contributions
The first draft was written by KM, together with ASW, DMG, and JT. CE, POO
and JN are the lead site investigators in the trial and contributed to the
drafting and revision of this manuscript. AM was responsible for study
coordination and training and all other authors were responsible for patient
enrollment and study conduct and contributed to the intellectual content
and revision of this manuscript. PO and DA were responsible for
coordination of data collection and quality control. MC, TS, CMD, VO, RW
participated in the data collection and interpretation of data. TNW, SU and
AM were responsible for the DNA extraction and genotyping and
interpretation of data. All authors read and approved the final manuscript.
Kathryn Maitland is the guarantor of the article.
Acknowledgements
We thank Jennifer A Evans, Department of Paediatrics, University Hospital of
Wales, Cardiff, and Imelda Bates, Department of International Public Health,
Liverpool School of Tropical Medicine for review of SAEs. We thank Dr
Benjamin Wabwire (Director) and members of the Mbale Regional Blood
Transfusion service for their support and assistance with the implementation
of this trial.
Page 10 of 11
Funding source
The study was supported by a grant (G0801439) from the Medical Research
Council, United Kingdom (provided through the MRC DFID concordat). The
funders had no role in study design, data collection and analysis, decision to
publish or preparation of the manuscript.
Author details
1
Department of Paediatrics, Mbale Regional Referral Hospital, Pallisa Road
Zone, PO Box 921, Mbale, Uganda. 2Department of Paediatrics, Soroti
Regional Referral Hospital, PO Box 289, Soroti, Uganda. 3Medical Research
Council (MRC) Clinical Trials Unit, Aviation House, 125 Kingsway, London
WC2B 6NH, UK. 4Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research
Programme, PO Box 230, Kilifi, Kenya. 5Wellcome Trust Centre for Clinical
Tropical Medicine, Department of Paediatrics, Faculty of Medicine, St Marys
Campus, Norfolk Place, Imperial College, London W2 1PG, UK.
Received: 20 December 2013 Accepted: 17 March 2014
Published: 25 April 2014
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doi:10.1186/1741-7015-12-67
Cite this article as: Olupot-Olupot et al.: Phase II trial of standard versus
increased transfusion volume in Ugandan children with acute severe
anemia. BMC Medicine 2014 12:67.
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