The effect of blood transfusion on outcomes among African children admitted to hospital with Plasmodium falciparum malaria: a prospective, multicentre observational study.
The effect of blood transfusion on outcomes among African children admitted to hospital with Plasmodium falciparum malaria: a prospective, multicentre observational study.
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DOI：
10.1016/s2352-3026(20)30288-x
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发表时间：
2020-11
期刊：
影响因子：
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通讯作者：
Casals-Pascual C
中科院分区：
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作者：
Ackerman H;Ayestaran A;Olola CHO;Jallow M;Agbenyega T;Bojang K;Roberts DJ;Krishna S;Kremsner PG;Newton CR;Taylor T;Valim C;Casals-Pascual C
在撒哈拉以南非洲，感染恶性疟原虫每年导致约40万名儿童严重疟疾和死亡。输血可能会让一些疟疾患者受益，但可能会伤害其他人。这项研究的目的是评估在恶性疟疾住院儿童中输血和死亡之间的关系。我们分析了位于冈比亚班珠尔、马拉维布兰太尔、加蓬兰巴雷内、加蓬利伯维尔、肯尼亚基里菲和加纳库马西的六家三级保健医院的入院情况，这些医院参加了非洲儿童严重疟疾网络。如果患者年龄在15岁以下，且血液涂片检测恶性疟原虫阳性，则纳入观察性研究。输血由知道当地和国际输血指南的负责任的医生自行决定。使用部位和严重程度调整的模型估计与输血相关的住院死亡几率。使用广义加性模型估计最佳的血红蛋白输注阈值。2000年12月3日至2005年3月8日期间，25893名恶性疟疾患者入院接受了这项研究。25893人中有8513人(32.8%)接受了输血。对患者进行随访，直到出院，中位数(IQR)为2(1-4)天。在部位调整分析中，输血与死亡几率降低相关(OR=0.82[95%CI 0.71~0.94])，在调整了输血患者疾病严重程度后(OR=0.50[95%CI 0.42~0.60])。在所有研究参与者中，当入院时血红蛋白达到77g/L(95%CI：65-110时)，输血与改善存活率有关。在意识受损的患者中，当血红蛋白浓度达到105g/L(95%可信区间71-115)时，输血可提高存活率。在高乳酸血症患者中，更高的血红蛋白浓度(95%可信区间下限：90g/L)与改善存活率的关联持续存在。全血输注与恶性疟原虫感染儿童存活率的提高密切相关。在意识受损或高乳酸血症的患者中，当血红蛋白浓度高于当前推荐的输血阈值时，输血与改善存活率有关。这些发现突显了进行随机对照试验的必要性，以测试患有严重疟疾并伴有意识障碍或血乳酸升高的非洲儿童的较高输血阈值。
Infection with Plasmodium falciparum leads to severe malaria and death in approximately 400,000 children each year in sub-Saharan Africa. Blood transfusion may benefit some patients with malaria but could potentially harm others. The aim of this study was to estimate the association between transfusion and death among children admitted to hospital with P. falciparum malaria. We analyzed admissions to six tertiary care hospitals located in Banjul, The Gambia; Blantyre, Malawi; Lambaréné, Gabon; Libreville, Gabon; Kilifi, Kenya; and Kumasi, Ghana that participated in the Severe Malaria in African Children (SMAC) network. Patients were enrolled in the observational study if they were under the age of 15 years and had a blood smear positive for P. falciparum. Blood transfusion was administered at the discretion of the responsible physicians who were aware of local and international transfusion guidelines. Odds of in-hospital death associated with transfusion were estimated using site- and severity-adjusted models. Generalized additive models were used to estimate optimal hemoglobin transfusion thresholds. 25,893 patients were admitted to hospital with P. falciparum malaria and enrolled in the study from December 3, 2000 through March 8, 2005. 8,513 (32·8%) of 25,893 received a blood transfusion. Patients were followed until discharge from hospital over a median (IQR) of 2 (1-4) days. Transfusion was associated with decreased odds of death in site-adjusted analysis (OR=0·82 [95%CI 0·71-0·94]) and after adjusting for the increased disease severity of transfused patients (OR=0·50 [95% CI 0·42-0·60]). Among all study participants, transfusion was associated with improved survival when the admission hemoglobin was up to 77 g/L (95% CI: 65-110). Among those with impaired consciousness, transfusion was associated with improved survival at hemoglobin concentrations up to 105 g/L (95% CI 71-115). Among those with hyperlactatemia, the association with improved survival persisted at even greater hemoglobin concentrations (lower bound of 95%CI: 90 g/L). Whole blood transfusion was strongly associated with improved survival among children with P. falciparum malaria. Among those with impaired consciousness or hyperlactatemia, transfusion was associated with improved survival at hemoglobin concentrations above the currently recommended transfusion threshold. These findings highlight the need to conduct randomized controlled trials to test higher transfusion thresholds among African children with severe malaria complicated by impaired consciousness or elevated blood lactate.