National registry may reduce mortality among alloimmunized people with sickle cell disease
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A nationwide red blood cell alloantibody exchange could reduce mortality among alloimmunized individuals with sickle cell disease, according to study results presented at ASH Annual Meeting and Exposition.
Use of a national system to share data from blood transfusions also could reduce the cost of care for this population, investigators concluded.
“We can do two things at the same time — we can save lives and save costs,” George Goshua, MD, MSc, assistant professor of medicine (hematology) at Yale School of Medicine, said in a press release. “It should be a no-brainer.”
Blood transfusions can be lifesaving for individuals with sickle cell disease; however, they carry the risk for delayed hemolytic transfusion reaction (DHTR).
DHTRs — which can happen days or weeks after transfusion — result from posttransfusion red blood cell alloimmunization. This occurs after exposure to non-self red blood cell antigens, putting individuals who have been pregnant or received a prior blood transfusion at elevated risk.
DHTRs are rare; however, they often require extended hospitalization and can be fatal. DHTR mortality is particularly high among people with sickle cell disease.
To reduce risk for DHTRs, physicians can compare donated blood with a patient’s alloantibody profile to determine if the blood selected for transfusion likely will be safe.
This information often is not shared between U.S. health systems, however, so physicians often do not take it into account when selecting blood.
Goshua and colleagues used a computer simulation to estimate the benefits and costs of creating a U.S. alloantibody exchange, which could serve as a central repository for alloantibody data accessible to physicians from all health care systems in the country.
They estimated the effects this type of repository would have on DHTR mortality and related health care costs for individuals with sickle cell disease, who are at higher risk for this complication due to their need for frequent blood transfusions.
Researchers built a Markov simulation of alloimmunized patients with sickle cell disease in the United States.
They used prospective (n = 311) and retrospective (n = 220) studies of DHTR incidence among people with sickle cell disease to inform transition probabilities for DHTR incidence and DHTR-specific mortality, and they accounted for age-, gender- and disease-specific background mortality probabilities.
They modeled cumulative probability of DHTR from age 5, using a lifetime horizon.
They calculated costs from the health system perspective and effectiveness in quality-adjusted life-years. They quantified cost-effectiveness using an incremental cost-effectiveness ratio, incorporating a willingness-to-pay threshold of $100,000 per quality-adjusted life-year.
Investigators assumed a $10 million lifetime operating cost for an alloantibody exchange. They also assumed no patient diagnosed with DHTR would have more than one DHTR recurrence, and that an exchange would not be able to prevent all DHTRs.
They incorporated prior estimates that 20% to 44% of people in the United States with sickle cell disease are alloimmunized.
Researchers determined an alloantibody exchange would reduce the lifetime risk for death due to DHTR among people with sickle cell disease who have antibodies from 5.7% to 2.4%. The peak probability decrease occurred at age 41 years (27% without the exchange vs. 10.6% with it).
Researchers calculated a lifetime population benefit for alloimmunized individuals with sickle cell disease in the United States of up to 15,710 quality-adjusted life-years gained.
Investigators estimated the exchange would result in a cumulative net savings of up to $1.5 billion over the lifetime of this current U.S. patient population, or $34,091 per alloimmunized patient registered in the exchange.
The model’s calculations appeared comparable to the benefits already demonstrated in the 10-year experience of the national Dutch Transfusion Register of Irregular Antibodies and Cross-match Problems, a real-world alloantibody exchange in the Netherlands.
However, Goshua and colleagues characterized their projected benefits as conservative.
They noted a national alloantibody exchange would benefit alloimmunized individuals with conditions other than sickle cell disease, such as autoimmune conditions, pregnancy, myelodysplastic syndrome and thalassemia.
The model also does not account for lives or costs saved for others who require blood transfusions, such as individuals undergoing cancer treatment.
“The findings from our model are pretty definitive,” Goshua said. “Despite very conservative assumptions, our results still show a huge financial benefit to having a system in place to serve as a preventive net that catches patients before they have to go through a [DHTR].”
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Goshua G, et al. Abstract 885. Presented at: ASH Annual Meeting and Exposition; Dec. 10-13, 2022; New Orleans.
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