Department of Medicine,
Division of Nephrology,
c
MBBS, FRCP, Professor of Medicine, Allama Iqbal Medical College/ Jinnah Hospital Lahore, Lahore, Pakistan
b
Summary
Background: Scientific data regarding effects of platelet
transfusion on platelet count in dengue-related thrombocytopenia is scanty. Methods: A single center, randomized non-blinded trial was conducted on adult patients with dengue fever and platelet counts less than
30,000/l. Patients were randomized to treatment and
control group. Treatment group received single donor
platelets. Patients with post-transfusion platelet increment (PPI) *10,000/l and/or corrected count increment
(CCI) *5,000/l 1 h post-transfusion were considered responders. Primary outcome was platelet count increments at 24 and 72 h. Results: 87 patients were enrolled,
and 43 (48.2%) received platelet transfusion. Mean PPI
and CCI at 1 h post-transfusion in the treatment group
were 18,800/l and 7,000/l respectively. 22 (53.6%) patients in the treatment group were non-responders.
Mean platelet increments at 24 and 72 h were higher in
the treatment group as compared to the control group.
Responders showed significantly higher increments
when compared to non-responders and the control
group at 24 h (p = 0.004 and p < 0.001, respectively) and
72 h (p = 0.001 and p < 0.001, respectively). Significant
differences were found between non-responders and the
control group at 24 h (p < 0.001), but not at 72 h (p =
0.104). Patients with lower baseline platelet count were
more likely to be non-responders. Platelet transfusion
neither prevented development of severe bleeding nor
Introduction
Dengue is the most prevalent mosquito borne viral disease
infecting over 50 million people each year [1]. Its clinical
symptoms vary from mild fever to life-threatening shock [2].
Thrombocytopenia is a prominent feature of dengue infection
[3]. A platelet count of less than 100,000/l is one of the diagnostic criteria for dengue hemorrhagic fever [4]. However, severe thrombocytopenia can be seen in both dengue fever and
dengue hemorrhagic fever. There is a significant negative correlation between disease severity and platelet count [5]. Although low platelet count and hypofibrinogenemia are the
two most prominent hemostatic defects responsible for bleeding in dengue infection [6], thrombocytopenia and coagulation abnormalities do not reliably predict bleeding in dengue
infection [7, 8]. Causes of thrombocytopenia include both
bone marrow suppression and platelet destruction. Immune
complex-mediated platelet destruction is probably the most
important factor contributing to thrombocytopenia in dengue
infection [6].
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Key Words
Dengue fever Dengue hemorrhagic fever
Single donor apheresis platelets Platelet transfusion
Corrected count increment CCI Transfusion reaction
Study Population
Adults of the age 14 years and above presenting with dengue fever or
dengue hemorrhagic fever, platelet counts less than 30,000/l, and having
no bleeding or mild bleeding (WHO grade 1 or 2 bleeding) were enrolled
in the study after taking written informed consent. Case definitions based
on WHO guidelines were used to diagnose dengue fever and dengue hemorrhagic fever [4]. Patients with other causes of thrombocytopenia (e.g.
idiopathic thrombocytopenic purpura, aplastic anemia), chronic ailments
(chronic liver disease, chronic kidney disease, cancers), prior history of
platelet transfusion and severe bleeding (WHO grade 3 and 4) were excluded from the study. Demographic data, history, and examination findings of all patients were recorded, and blood samples were drawn to
measure the platelet counts. Patients were randomized into treatment or
control group. The treatment group received single donor platelet (SDP)
transfusion while the control group did not receive any platelet transfusion. Filtered apheresis platelets from a single donor (dose fixed at * 5
1011 platelets) were collected with a Haemonetics model MCS+LN 9000
apheresis machine (Haemonetics Corp., Braintree, MA, USA). All transfusions were done within 1 h of apheresis.
Measurement of Platelet Increments
Blood samples were collected in EDTA anticoagulated vials, and
platelet counts were measured by automated count analyzer. In order to
avoid pseudo-thrombocytopenia, citrated samples were used to repeat
platelet counts if EDTA-induced platelet clumping was seen [13]. Platelet
counts were obtained at baseline (P0), 24 h (P24), and 72 h (P72) for all
patients. Additionally, platelet counts were also obtained within 10 min to
1 h post transfusion (P1) for the treatment group (fig. 1).
Corrected count increment (CCI) was determined using the following
formula:
CCI = (PPI BSA (m2)) 1011/ number of platelets transfused
(1).
PPI represents the post-transfusion platelet increment (post-transfusion platelet count minus pre-transfusion platelet count), and BSA is the
body surface area measured in square meters. We used Mosteller formula
for calculating BSA.
We measured PPI and CCI at 10 min to1 h post-transfusion in the
treatment group. Based on their responsiveness to platelet transfusion,
patients in the treatment group were further divided into responders and
non-responders. Patients with PPI * 10,000/l and/or CCI * 5,000/l 1 h
post-transfusion were considered responders; the rest were considered
non-responders.
PPI at 24 and 72 h were calculated using the following formulas (fig. 1):
PPI at 24 h = platelet count at 24 h platelet count at baseline
PPI at 72 h = platelet count at 72 h platelet count at baseline
(2),
(3).
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Study De sign
The study was a single-center, parallel-assignment, randomized, nonblinded prospective analysis of increments in platelet counts in patients
with dengue infection who received platelet transfusion therapy versus
those who did not. The study was conducted in a high-dependency unit
for dengue in Jinnah Hospital Lahore, Pakistan. Ethical review board of
the hospital approved the protocol that meets the standards of the Declaration of Helsinki in its revised version of 1975 and its amendments of
1983, 1989, and 1996.
For the treatment group, we calculated the spontaneous platelet recovery at 24 h using following formula:
Spontaneous platelet recovery at 24 h = PPI at 24 h PPI at
1 h post-transfusion
(4).
Results
Comparison of PPI
Comparison between Treatment and Control Groups
Mean PPI at 24 h was 34,780/l in the treatment group
364
Comparison of Bleeding
Amongst patients with bleeding at baseline, progression to
WHO grade 3 bleeding was observed in 1 patient (responder)
in the treatmentgroup but in none in the control group. The
patient received two pints of RBC transfusion. The mean time
to cessation of bleeding was 31.6 h in the treatment group and
25.2 h in the control group. However, this difference was not
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Table 1. Baseline
characteristics of the
patients
Characteristics
Treatment group
(N = 43)
Control group
(N = 44)
Total
(N = 87)
Age, years
Median
Range
33
1565
36
1678
34
1578
28 (65)
15 (35)
29 (66)
15 (34)
57 (65)
30 (35)
17 (40)
08 (18)
18 (42)
0
20 (46)
06 (14)
18 (41)
0
37 (42)
14 (16)
36 (42)
0
10,000
8,00015,000
10,500
9,00017,700
19 (44)
20 (45)
39 (45)
11 (58)
01 (05)
04 (21)
03 (16)
15 (75)
04 (20)
00 (00)
01 (05)
26 (66)
05 (14)
04 (10)
04 (10)
09 (47)
10 (53)
06 (30)
14 (70)
15 (38)
24 (62)
DF = Dengue fever; DHF = Dengue hemorrhagic fever; DSS = Dengue shock syndrome; WHO = World Health
Organization.
Parameter
Treatment group
Control group
P value
PI24, platelets/l
Mean SD
Median
Interquartile range
34,780 43,820
22,000
12,00045,750
4,280 10,360
3,000
2,000 to 9,000
<0.001
PI72, platelets/l
Mean SD
Median
Interquartile range
75,430 69,465
53,500
31,75089,250
32,840 30,900
23,000
9,00057,000
<0.001
Spontaneous increment at 24 h
Mean SD
Median
Interquartile range
4,525 38,080
1,500
5,750 to 10,000
4,280 10,360
3,000
2,000 to 9,000
0.327
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Responders (R)
R vs. NR
p value
Non-responders
(NR)
NR vs. C
p value
Controls (C)
C vs. R
p value
P0, platelets/l
Mean SD
Median
Interquartile range
14,315 7,265
14,000
10,00020,000
0.012
9,710 4,410
9,000
7,50011,500
0.019
13,300 6,400
10,500
9,00017,700
0.384
PI24, platelets/l
Mean SD
Median
Interquartile range
53,310 56,760
38,000
18,00081,000
0.007
18,770 16,800
16,000
9,00031,000
<0.001
4,280 10,360
3,000
2,000 to 9,000
<0.001
PI72, platelets/l
Mean SD
Median
Interquartile range
103,440 72,950
72,000
52,000130,000
0.002
51,430 58,660
34,000
18,00065,500
0.110
32,840 30,900
23,000
9,00057,000
<0.001
Spontaneous increment at 24 h
Mean SD
Median
Interquartile range
5,050 53,680
1,500
33,000 to 11,000
0.456
4,050 15,275
2,000
5,000 to 11,500
0.631
4,372 10,360
3,000
2,000 to 9,000
0.258
Parameter
P0
<10,000
P0
11,00020,000
Number of cases
Treatment group
Control group
21
22
14
16
5
6
Bleeding, yes
Number of cases
15
18
0.090
7
8
6
12
2
4
0.707
P0
21,00030,000
P value
0.972
06 (29)
15 (71)
09 (64)
05 (36)
04 (80)
01 (20)
0.035
0.035
Adverse events,
Transfusion reactions
Death
2
1
0
0
0
0
0.774
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Adverse Events
Three patients in the treatment group (7%) showed severe
anaphylactic reaction and hypotension. There were 2 deaths
in the treatment group. One death was due to development of
transfusion-related acute lung injury (TRALI) while the other
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were significantly more non-responders in patients with baseline platelet count < 10,000/l. On the other hand, progression
to WHO grade 3 bleeding occurred in a patient with a baseline platelet count > 20,000/l.
Discussion
Pathogenesis of thrombocytopenia in dengue infection is not
fully known and may be multifactorial. Immune-mediated destruction of platelets is considered to be the most important
factor. For example, one study found presence of antibodies directed against dengue virus nonstructural protein 1 (NS1) that
showed cross-reactivity with human platelets and endothelial
cells, which lead to platelet and endothelial cell damage and
inflammatory activation [15]. In most patients, bone marrow
responds to peripheral platelet destruction with increased production of platelets. Over time, immune-mediated destruction
of platelets ends and spontaneous recovery in platelet counts is
seen in almost all patients. The degree of thrombocytopenia
varies in dengue infection, and platelet count may be extremely
low in few patients. Platelet transfusions have been done in
many patients with dengue related thrombocytopenia; however, response to platelet transfusion is not fully studied in
these patients. The present study provides insight to the response of platelet transfusion in dengue infection.
The normal response to platelet transfusion is an immediate increase in the platelet count that is maximal at about 10
min to 1 h post-transfusion. Following this, there is a steady
linear decrease in the platelet count, which usually returns to
baseline at about 72 h post-transfusion. Infusion of one apheresis unit or six units of whole blood-derived platelets to an
adult with a body surface area of 2.0 m2 raises the platelet
count by approximately 30,000/l at 1 h after the infusion.
CCI is a more qualitative way to determine adequacy of the
response to platelet transfusion. The theoretically expected
value of the CCI is approximately 20,000/l. However, in
practice the observed increase in platelet count following
transfusion in many patients is often less than expected, and
the CCI value is closer to 10,000/l. The response to platelet
transfusion is usually assessed in patients with hematological
and oncological disorders by measuring post-transfusion PPI
and CCI. Refractoriness or poor response to platelet transfusions is aasumed when two consecutive platelet transfusions
lead to 10-min to 1-hour post-transfusion CCI values of less
than 5,000/l [16]. However, unlike hematological disorders,
dengue-related thrombocytopenia lasts for shorter duration,
and repeated platelet transfusions are not usually required.
Hence, a low CCI on two consecutive transfusions is difficult
to document in order to establish refractoriness. Therefore,
we avoided using the term refractoriness and divided recipients into responders and non-responders on the basis of response to one single donor platelet transfusion.
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Conclusion
In this trial, half of the patients showed almost no response
to a high-dose platelet transfusion. Platelet transfusion did
not prevent development of severe bleeding or shorten time
to cessation of bleeding and was associated with significant
side effects. Although patients with lower platelet counts are
more likely to receive platelet transfusion, they are less likely
to show an appropriate response. Therefore, platelet transfusion should not be routinely done in the management of dengue fever.
Disclosure Statement
The authors declare no conflict of interest.
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