Supplementary Appendix

Transcription

1 Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Heddle NM, Cook RJ, Arnold DM, et al. Effect of short-term vs. long-term blood storage on mortality after transfusion. N Engl J Med 2016;375: DOI: /NEJMoa

2 Table of Contents Appendix INFORM Study Trial Investigators and Support Staff...1 Appendix Table S1: Summary of country policies about storage for the red cells and transfusion thresholds....3 Table S2: Summary of the main diagnosis codes (version 10 of the International Classification of Diseases) that were used to categorize the primary reason for patient length of hospital stay....4 Section A: Patients with blood types A and O...6 Table S3: Summary of the number of red cells transfused and storage duration by study center and treatment arm for patients with blood types A and O...6 Table S4: Summary of mortality information, demographic data and transfusion data for the three high-risk subgroups of blood type A and O patients (patients having cardiovascular surgery, patients admitted to the intensive care unit, and patients with cancer)....7 Figure S1: Cumulative incidence plot of in-hospital mortality by treatment group for patients with blood types A and O....8 Figure S2: Secondary analysis blood type A and O patients: Forest plot showing the hazard ratios (HR) for in-hospital death using the stratified cox regression model including the overall analysis and high-risk subgroups....9 Section B: Patients with blood types A, O, B, and AB (all patients)...10 Table S5: Demographic data on randomized patients of blood types A, O, B, and AB that were admitted to hospital and transfused red cells Table S6: Summary of blood products transfused to patients of blood types A, O, B, and AB...11 Table S7: Summary of the number of red cells transfused and storage duration by study center and treatment arm for all patients (A, O, B, and AB) Figure S3: Plots showing the storage age distribution of red cells transfused to all patients (blood types A, O, B, and AB); only patients with blood types A and O patients; and by individual blood types Figure S4: Forest plot showing the odds ratios for in-hospital death (all patients - blood types A, O, B, and AB) using a logistic regression model (stratified by study center and blood type) including: the overall analysis: subgroup analyses by hospital site, country, patient blood type and diagnosis; and high-risk subgroups Figure S5: Cumulative incidence plots of in-hospital mortality by treatment group for the overall analysis of all patients (blood types A, O, B, and AB) Figure S6: Forest plot showing the hazard ratios (HR) for in hospital death using the stratified cox regression model including the overall analysis; and high-risk subgroups for all patients (blood types A, O, B, and AB) References...17

3 Appendix 1 INFORM Study Trial Investigators and Support Staff The following individuals who participated in the INFORM study (in alphabetical order): Steering Committee/INFORM Trial Investigators: Donald M. Arnold, Rebecca L Barty, Richard J. Cook, Mark A. Crowther, P.J. Devereaux, John W. Eikelboom*, Martin Ellis, Priscilla Figueroa, Nancy M. Heddle*, Jack Hirsh, Andrea Kurz, Yang Liu, David Roxby, Daniel I. Sessler, Magdalena Sobieraj-Teague, Theodore E. Warkentin, Kathryn E Webert. *Co-Principal Investigators Writing Committee: Nancy M. Heddle created the first draft of the manuscript. The Steering Committee edited the manuscript and approved it s submission. Data Safety Monitoring Board: Janet Raboud (biostatistician) Robert Skeate (transfusion medicine expert), Stephen Vamvakas (Chair of committee, pathologist/epidemiologist), Qi-Long Yi (biostatistician). December 2014 Dr Raboud resigned from the committee and was replaced by Dr. Qi-Long Yi. Study Clinical Coordinating Center (McMaster Centre for Transfusion Research): Rebecca Barty, Richard J. Cook, Nancy M. Heddle, Yang Liu. Institutions, Site Investigators and Coordinators and Laboratory Staff: [number of randomized patients is provided in parentheses]: Australia: Flinders Medical Centre, David Roxby (co-investigator, site principal co-investigator), Romi Sinha (data manager), Magdalena Sobieraj-Teague (co- principal co-investigator) [7,276]. Canada: Hamilton Health Sciences, Hamilton General Hospital and Hamilton Health Sciences, Juravinski Hospital, John. W. Eikelboom (co-investigator, site principal investigator), Theodore E. Warkentin (coinvestigator, TMS director) [6,820; 3,721 respectively], St. Joseph s Healthcare Centre, Mark A. Crowther (co- 1

4 investigator, site principal investigator), Transfusion Medicine Staff, Hamilton Regional Laboratory Medicine Program [2,034]. Israel: Meir Medical Center Kfar Saba and Sackler School of Medicine, Martin Ellis (co-investigator, site principal investigator), Eizenshtat Yehudit (coordinator), Sharon Yudit (laboratory) [1,620]. United States of America: Cleveland Clinic, Cameron Egan (research coordinator), Matthew Hutcherson (research coordinator), Priscilla Figueroa (co-investigator, Head, Section of Transfusion Medicine and Director Hematopoietic Progenitor Cell Laboratory), Andrea Kurz (co-investigator, site principal co-investigator), Daniel I. Sessler (co-investigator) [10,026]. 2

5 Supplementary Analysis Information Appendix 2 Table S1: Summary of country policies about storage for the red cells and transfusion thresholds. Country Storage of red cells* Transfusion triggers Australia Red cells (for neonates): 35 days. All other red cells: 42 days. Policies in place with the majority being between g/l as accessed on the National Blood Authority website (url: 1 Canada 42 days. Transfusion triggers for non-bleeding patients range for 70g/L to 80g/L depending on the patient population. Israel United States Most red cells are stored for 35 days (75%). 25% of the red cells is stored in SAGM for a maximum of 42 days. Greater than 98% of the red cells given during INFORM had a maximum storage duration of 42 days. The remaining red cells had a 35 day storage limit. Patients in intensive care 70 g/l. Unstable cardiac patients 80 g/l to 100 g/l. Triggers for other patients range for 70/g/L to 90 g/l. Transfusion triggers for non-bleeding patients range for 70g/L to 80g/L depending on the patient population. 3

6 Table S2: Summary of the main diagnosis codes (version 10 of the International Classification of Diseases) that were used to categorize the primary reason for patient length of hospital stay. ICD-10 Main Diagnosis Categories Certain infectious and parasitic diseases (A00-B99) Neoplasms (C00-D48) Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) Endocrine, nutritional and metabolic diseases (E00-E90) Diseases of the circulatory system (I00-I99) Diseases of the respiratory system (J00-J99) Diseases of the digestive system (K00-K93) Diseases of the musculoskeletal system and connective tissue (M00-M99) Diseases of the genitourinary system (N00-N99) Pregnancy, childbirth and the puerperium (O00-O99) Certain conditions originating in the perinatal period (P00- P96) Symptoms, signs and abnormal clinical and This category includes: Bacterial, viral, and parasitic diseases including (but not limited to), intestinal infections, sepsis, and sexually transmitted infections. Malignant, in situ, or benign neoplasms which may be on a known or unspecified site. Neoplasms with uncertain or unknown behaviour are also included. Predominately a description of various types of anaemias. haemorrhagic conditions, coagulation defects, diseases of the blood (including bloodforming organs), and disorders involving the immune system are also included. Disorders of the endocrine glands; metabolic, glucose, and/or pancreatic associated disorders (e.g. diabetes); and various nutritional conditions (e.g. obesity, malnutrition). Various heart (e.g. ischemic, pulmonary, rheumatic) and cerebrovascular diseases. Hypertensive diseases, diseases of the blood (venous, arterial) and lymphatic vessels, and lymph nodes are also included. Acute and chronic diseases of the upper and lower respiratory tracts, including various respiratory infections. Lung diseases caused by external agents, and diseases affecting the interstitium or pleura are also included. Diseases affecting the various parts of the digestive system, such as the salivary glands, abdominal organs, and the peritoneum. Arthropathies, dorsopathies, osteopathies, and chrondropathies. Soft tissue and systemic connective tissue disorders are also included. Diseases affecting the kidney and its function, such as renal failure. Diseases of the genitourinary organs, disorders of the breasts, glomerular and renal tubulo-interstitial diseases are also included. Events linked to or exacerbated by pregnancy, childbirth or by the puerperium (maternal or obstetric causes). Illnesses derived within the perinatal period, death or morbidity may result at a later time (e.g. birth trauma, infection specific to the perinatal period). Symptoms and signs of the various body systems (e.g. nervous, respiratory), which are not classified elsewhere. Abnormal findings of 4

7 laboratory findings, not elsewhere classified (R00- R99) Injury, poisoning and certain other consequences of external causes (S00-T98) Factors influencing health status and contact with health services (Z00-Z99) body fluids (e.g. blood, urine), substances and tissues without diagnosis, as well as poorly-defined or unknown causes of death are also included in this category. External causes resulting in injury at a single or multiple sites, as well as the toxic effects or poisoning due to various substances. Other conditions described include frostbite, burns and corrosions, and complications associated with surgical and medical care, not elsewhere classified. Factors influencing individual health status (e.g. potential health hazards related to communicable disease) and reasons for contact with health services (e.g. specific procedures, examination and investigations) The following categories were classified in Table 1 and Table S5 as Other. ICD-10 This category includes: Mental and behavioural Various mental and behavioral disorders, including (but not limited to) disorders (F00-F99) schizophrenia; disorders caused by psychoactive substance use; and personality disorders Diseases of the nervous system (G00-G99) Diseases of the eye and adnexa (H00-H59) Diseases of the ear and mastoid process (H60-H95) Diseases of the skin and subcutaneous tissue (L00- L99) Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) External causes of morbidity and mortality (V01-Y98) Various diseases of the central nervous system (e.g. inflammatory, atrophic, degenerative, demyelinating). Movement disorders (e.g. Parkinson disease), episodic disorders (e.g. epilepsy), disorders of the peripheral nervous system, and paralytic syndromes (e.g. cerebral palsy) are also included. Disorders associated with various parts of the eye, including the nerves and ocular muscles. Visual disturbances, blindness, and glaucoma are also included. Disorders of the ear and mastoid, with diseases grouped by site (external, middle and mastoid, and/or inner ear). Various diseases of the skin and subcutaneous tissue including (but not limited to) inflammatory/infectious conditions (e.g. dermatitis), and disorders of the skin appendages. Congenital malformations, grouped by site (e.g. nervous system, respiratory system, genital organs), and/or chromosomal abnormalities. Descriptors of environmental events (e.g. exposure to forces of nature), and other circumstances (e.g. accidents, physical harm, complications of surgical and medical care) as the cause of injury, poisoning, and other adverse events (morbidity, mortality). 5

8 Section A: Patients with blood types A and O Table S3: Summary of the number of red cells transfused and storage duration by study center and treatment arm for patients with blood types A and O. Treatment Group Short Term Storage Group Long Term Storage Group Total red cells Median (q1, q3) Total red cells Median (q1, q3) transfused transfused Australia site 5,307 9 (7, 12) 11, (15, 27) Canadian site 1 5, (8, 16) 11, (24, 35) Canadian site 2 3, (8, 16) 7, (18, 32) Canadian site 3 1, (9, 17) 3, (20, 35) Israel site (4, 11) 1, (18, 27) U.S. site 8, (8, 18) 15, (13, 27) 6

9 Table S4: Summary of mortality information, demographic data and transfusion data for the three highrisk subgroups of blood type A and O patients (patients having cardiovascular surgery, patients admitted to the intensive care unit, and patients with cancer). Patients having cardiovascular surgery Short-Term Long-Term Storage Storage Group Group (n=3,051) (n=6,234) High-risk subgroups Patients admitted to the intensive care unit Short-Term Long-Term Storage Storage Group Group (n=3,553) (n=7,025) Patients with cancer Short-Term Storage Group (n=891) Long-Term Storage Group (n=1,931) Variable Mortality, n (%) 376 (12.3) 697 (11.2) 472 (13.3) 901 (12.8) 75(8.4) 169 (8.8) Female, n (%) 1,288 (42.2) 2,722 (43.7) 1,533 (43.1) 3,102 (44.2) 455 (51.1) 960 (49.7) Age at admission (years), 68 (58, 77) 68 (57, 77) 68 (58, 77) 68 (58, 77) 65 (55, 73) 65 (55, 74) median (q1, q3) Blood Type, n (%) A 1,450 (47.5) 2,986 (47.9) 1,720 (48.4) 3,350 (47.7) 434 (48.7) 912 (47.2) O 1,601 (52.5) 3,248 (52.1) 1,833 (51.6) 3,675 (52.3) 457 (51.3) 1,019 (52.8) Total number of red cells transfused # of red cells transfused/patient, median (q1, q3) min, max # of red cells transfusion episodes/patient median (q1, q3) min, max 14,948 29,521 16,600 32,574 3,562 7,660 3(2, 6) 1, (2, 5) 1, 92 3 (2, 5)1, (2, 5) 1, 84 2 (2, 4) 1, 53 2 (2, 4) 1, 78 2 (1, 3) 1, 87 2 (1, 3) 1, 58 2 (1, 3) 1, 87 2 (1, 3) 1, 50 1 (1, 2)1,36 1 (1, 2)1, 38 Duration of storage of transfused red cells (days) Mean (SD) 13.8 (8.0) 23.8 (9.0) 13.4 (7.8) 23.6 (9.1) 14.4 (8.0) 22.8 (8.7) Median (q1, q3) 12 (8, 17) 23 (17, 31) 11 (8, 16) 23 (16, 31) 12 (8, 18) 22 (16, 29) Median (q1,q3) of the mean age of red cells transfused/patient 11.5 (8.0, 16.0) 24.8 (18.0, 31.0) 11.0 (8.0, 15.8) 24.4 (18.0, 30.8) 11.0 (8.0, 16.0) 23.0 (17.0, 29.0) 7

10 Figure S1: Cumulative incidence plot of in-hospital mortality by treatment group for patients with blood types A and O. 8

11 Figure S2: Secondary analysis blood type A and O patients: Forest plot showing the hazard ratios (HR) for in-hospital death using the stratified cox regression model including the overall analysis and highrisk subgroups. 9

12 Section B: Patients with blood types A, O, B, and AB (all patients) Table S5: Demographic data on randomized patients of blood types A, O, B, and AB that were admitted to hospital and transfused red cells. Characteristic Short-Term Storage Group (n=8,215) Long-Term Storage Group (n=16,521) Female, n (%)** 4,100 (49.9) 8,215 (49.7) Age at admission (years), median (q1, q3) min, max 69 (57, 79) 18, (57, 79) 17, 104 Blood Type, n (%) A 3,307 (40.3) 6,613 (40.0) AB 312 (3.8) 618 (3.7) B 967 (11.8) 1,981 (12.0) O 3,629 (44.2) 7,309 (44.2) Diagnosis category, n (%) Certain infectious and parasitic diseases 260 (3.2) 453 (2.7) Neoplasms 1,065 (13.0) 2,264 (13.7) Diseases of the blood and blood-forming organs and certain disorders 510 (6.2) 996 (6.0) involving the immune mechanism Endocrine, nutritional and metabolic diseases 204 (2.5) 392 (2.4) Diseases of the circulatory system 2,285 (27.8) 4,542 (27.5) Diseases of the respiratory system 360 (4.4) 670 (4.1) Diseases of the digestive system 971 (11.8) 1,957 (11.8) Diseases of the musculoskeletal system and connective tissue 406 (4.9) 785 (4.8) Diseases of the genitourinary system 277 (3.4) 622 (3.8) Pregnancy, childbirth and the puerperium 168 (2.0) 356 (2.2) Symptoms, signs and abnormal clinical and laboratory findings, not 234 (2.8) 484 (2.9) elsewhere classified Injury, poisoning and certain other consequences of external causes 1,151 (14.0) 2,252 (13.6) Factors influencing health status and contact with health services ǂ 144 (1.8) 290 (1.8) Other 180 (2.2) 458 (2.8) ** For one patient (0.005%) the sex was missing. Based on the Main Diagnosis Category (ICD-10; or ICD-9 classification for the US and Israel sites). The main diagnosis was missing for 67 patients (0.3%). ǂ Category includes factors influencing individual health status (e.g. potential health hazards related to communicable disease) and reasons for contact with health services (e.g. specific procedures, examination and investigations). Category includes symptoms and signs of the various body systems (e.g. nervous, respiratory), which are not classified elsewhere, and abnormal findings of body fluids (e.g. blood, urine), substances and tissues without diagnosis, as well as poorly-defined or unknown causes of death. Includes ICD-10 categories where the frequency of patients within each group was 1% or diagnosis was missing (see supplementary appendix Table S2 for a more detailed description of all 21 Main Diagnosis categories). None of the baseline characteristics were significantly different between the two groups at a significance level of

13 Table S6: Summary of blood products transfused to patients of blood types A, O, B, and AB. Short-Term Storage Group Long-Term Storage Group p-value Variable (n=8,215) (n=16,521) Median time from randomization to issue of the first red-cell 0.1 (0, 0.5) 0.1 (0, 0.6) unit for transfusion (hours) (q1, q3) Total number of red-cell units transfused 30,185 60,424 # of red-cell units transfused/patient, Median (q1, q3) min, max 2 (2, 4) 1, (2, 4) 1, # of red-cell transfusion episodes*/patient, Median (q1, q3) min, 1 (1, 2) 1, 87 1 (1, 2) 1, max Duration of storage of transfused red cells (days) < Mean (SD) 13.4/ /8.9 Median (q1, q3) 11 (8, 17) 23 (16, 31) Median (q1,q3) of the mean age of red cells transfused/patient 11.0 (8.0, 15.6) 24.0 (18.0, 30.0) < Median (q1,q3) of the oldest red cells transfused/patient 13 (9, 19) 27 (20, 35) < Other transfusions: Number of patients (%) Platelet transfusion 1,503 (18.3) 3,040 (18.4) 0.84 Plasma transfusion 1,335 (16.3) 2,689 (16.3) 0.99 Cryoprecipitate transfusion 455 (5.5) 881 (5.3) 0.46 *A transfusion episode is defined as all red-cell transfusions given on a single day. The protocol required a minimum 10 day difference in mean red cell storage duration between treatment groups. 11

14 Table S7: Summary of the number of red cells transfused and storage duration by study center and treatment arm for all patients (A, O, B, and AB). Long-Term Storage Group Long-Term Storage Group Number of red-cell Median (q1, q3) Number of red-cell Median (q1, q3) units transfused units transfused Australia site 6, (7, 13) 13, (15, 28) Canadian site 1 6, (9, 17) 13, (23, 35) Canadian site 2 4, (8, 16) 8, (18, 32) Canadian site 3 2, (9, 18) 3, (20, 35) Israel site 1,207 7 (4, 12) 2, (18, 27) U.S. site 9, (8, 19) 19, (13, 27) 12

15 Figure S3: Plots showing the storage age distribution of red cells transfused to all patients (blood types A, O, B, and AB); only patients with blood types A and O patients; and by individual blood types. 13

16 Figure S4: Forest plot showing the odds ratios for in-hospital death (all patients - blood types A, O, B, and AB) using a logistic regression model (stratified by study center and blood type) including: the overall analysis: subgroup analyses by hospital site, country, patient blood type and diagnosis; and highrisk subgroups. 14

17 Figure S5: Cumulative incidence plots of in-hospital mortality by treatment group for the overall analysis of all patients (blood types A, O, B, and AB). 15

18 Figure S6: Forest plot showing the hazard ratios (HR) for in hospital death using the stratified cox regression model including the overall analysis; and high-risk subgroups for all patients (blood types A, O, B, and AB). 16

19 References 1. Patient Blood Management Guidelines. National Blood Authority Australia, (Accessed September 13, 2016, at 2. International Statistical Classification of Diseases and Related Health Problems 10th Revision. World Health Organization, (Accessed September 12, 2016, at 17