Improving the Evaluation and Management of Transfusion-Related Iron Overload (TRIO) in Children, Adolescents, and Young Adults Following Cancer Treatment or Hematopoietic Stem Cell Transplantation

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Purpose Transfusion-Related Iron Overload (TRIO) is a late effect of therapy impacting survivors of childhood cancer and hematopoietic stem cell transplantation (HSCT) who receive frequent packed red blood cell (pRBC) transfusions. Surprisingly, there are no accepted guidelines to assist providers in identifying and treating at-risk patients following therapy. Our primary aim was to create an evidence-based clinical practice guideline (CPG) for the surveillance of TRIO and measure its impact on care at Helen DeVos Children’s Hospital. Methods We compared the rates at which screening laboratory and confirmatory imaging studies were obtained two years before and six months after CPG implementation. Results Labs more commonly obtained post-implementation included iron studies such as TIBC (p = .0077), TSAT (p= .0133), and serum iron (p = .0208) and hepatic injury markers such as AST/ALT (p= .0278), ALP (p = .0073), and total bilirubin (p = .0026). Liver MRI/FerriScan (p = .0343) and echocardiogram were also more commonly obtained post-implementation. We additionally found a positive correlation between HSCT and TRIO (p= .0010) and number of pRBC transfusions and TRIO (p= .0025). Gender, age, and weight did not impact the rates of TRIO in either cohort. There was no association between diagnosis category (solid tumor, leukemia/lymphoma, or non-malignant disease) and TRIO. Among HSCT patients, we did not find any relationship between TRIO and donor source, ABO compatibility status, or the type of conditioning therapy. Conclusion The implementation of a TRIO CPG can significantly influence post-therapy care. Although our cohort size was limited, we did not observe an association between gender, age, weight, diagnosis category, donor source, ABO compatibility status or HSCT conditioning modality and a diagnosis of TRIO.

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