Selective Leukoreduction is all that we Need in Low- and Middle-Income Countries

With the advent of medical technology nowadays, there is a popular say - “Universal leukoreduction is the need of the hour.”

Patients who require multiple transfusions of red blood cells (RBCs) and platelets are simultaneously at risk of developing febrile nonhemolytic transfusion reactions (FNHTRs), human leukocyte antigens (HLAs) alloimmunization, refractoriness to RDPs, and/or Cytomegalovirus (CMV) disease; leukoreduction of the blood components is currently an appropriate medical practice for them.

Several randomized controlled trials (RCTs) show the benefits of leukoreduction. On the basis of those, a contentious of implementing universal leukoreduction is growing.

It might be rational for developed countries but not for low- and middle-income countries (LMICs). The following points will justify - Selective leukoreduction is all we need in LMICs.

1. RCTs on highly selected patient groups, i.e., patients with hematologic malignancies or neonates, show the benefits of leukoreduction.[¹] However, no factual proof exists with other special populations of patients, such as surgical or trauma patients, would also experience decreased complications of allogeneic blood transfusion if universal leukoreduction was to be implemented. Such a prediction cannot be made, on the basis of few studies
2. Regarding FNHTRs. Very interesting to know that patients who receive RBC (Chronically) <1% of them experience FNHTRs, and the recurrence of reactions is <20% of those subjects. There are many individuals who receive blood transfusions only once or twice in their lifetime and never encountered such complications. Not all RCTs have revealed a reduction in the risk of FNHTRs. In the RCTs of Heddle et al.,[³] poststorage leukoreduction reduced the risk of FNHTRs to platelets but do not reduce alloimmunization to platelets (TRAPStudy).[²] Similarly, in the Viral Activation Transfusion Study, prestorage leukoreduction did not reduce the risk of FNHTRs to red cells.[⁴] Regarding platelet, only 2% of all transfusions result in severe reactions that need to execute preventative measures[²]
3. Platelet refractoriness: Clinical observation says - reduction in the risk of refractoriness may not alter a patient's clinical outcome. In the TRAP Study, though the absolute reduction in the risk of refractoriness was 10% and there were no differences between the trial arms in the risk of hemorrhagic events, the overall mortality, or the number of red cell or platelet transfusions received.[²] Mortality was 10% in controls, as compared with 14% in recipients of filtered platelets[²]
4. HLA-alloimmunization: Unfortunately, no valid studies on HLA alloimmunization have been conducted in surgical patients who represent the majority of the transfused subjects
5. CMV-Transmission of CMV by transfusion is currently a rather uncommon event. Prevention of CMV transmission to immune-competent recipients does not provide any visible benefit[⁵]
6. TRIM: If transfusion-associated immunomodulation really is the cause of many adverse effects (i.e., recurrence of cancer, postoperative infection, virus activation, or multiple-organ failure resulting in increased mortality), these would affect many or almost all patients who have undergone any transfusion
7. Global Economic Condition: The effects of the COVID-19 pandemic and the Russia-Ukraine war have made the global economy unstable. In this scenario, universal leukoreduction is not feasible for LMICs and selective leukoreduction is a feasible option in such settings.

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Conflicts of interest

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