Red Blood Cell Exchange Transfusion May Be Beneficial in Patients With Sickle Cell Disease and COVID-19

According to a case study published in Clinical Case Reports, red blood cell exchange transfusion (RBCX) appears be beneficial in patients with sickle cell disease and COVID-19.

The authors propose prophylactic RBCX prior to respiratory deterioration in these patients to prevent the need for intubation and intensive care unit (ICU) admission.

The report presented the first documented case of a 69-year-old African American female patient with a history of sickle cell disease with hereditary persistence of fetal hemoglobin that presented to the emergency department in sickle cell crisis and with COVID-19 infection.

Upon presentation, she reported joint pain and fever lasting 2 days. On admission, she had no known prior exposure to COVID-19 and denied experiencing the common symptoms of COVID-19, yet reported a positive test for COVID-19, which was confirmed after admission.

The patient was initially hemodynamically stable and afebrile with oxygen saturation of 95% on room air, but bilateral crackles were noted with physical examination. She also had elevated inflammatory markers of D-dimer >5250 ng/mlDDU (normal 0-316 ng/mlDDU), lactate dehydrogenase of 324 units/L (normal 84–246 units/L), C-reactive protein of 1.3 mg/dl (normal 0–1.0 mg/dl), and a hemoglobin of 6.4 g/dl (normal 11.2-15.7 g/dl). Computed tomography angiogram of the chest revealed extensive bilateral ground-glass subpleural opacities.

The patient was admitted for sickle cell crisis, symptomatic anemia, and COVID-19 pneumonia. She was transfused with a unit of packed red blood cells and initiated ceftriaxone, azithromycin, convalescent plasma, remdesivir, dexamethasone, zinc, vitamin C, and vitamin D.

After 2 days, the patient experienced acute shortness of breath with an oxygen saturation of 87% on nonrebreather (NRB), followed by rapid respiratory failure. Her heart rate was 160 to 170 beats per minute and oxygen saturation dropped to 65% to 70% on NRB. She was sedated, intubated, and placed in prone position for 16 hours. Following intubation, the patient’s arterial blood gas (ABG) showed pH of 7.287, PCO₂ of 30.0 mmHg, PO₂ of 318.4 mmHg, and HCO₃ of 14.2 mM/L with P/F ratio of 318.40 on FiO₂ of 100%.

She then received RBCX to prevent further respiratory failure. Initially 10 units of hemoglobin S negative, leukocyte reduced RBCs were transfused overnight. After RBCX, she had hemoglobin A of 92.1%, hemoglobin A2 of 2.5%, hemoglobin C of 0.0%, hemoglobin F of 0.0%, and hemoglobin S of 5.4%. Another unit of convalescent plasma was transfused the next day. On the following day, the ABG revealed pH of 7.487, PCO₂ of 28.3 mmHg, PO₂ of 144.8 mmHg, and HCO₃ of 21.0 mM/L with P/F ratio of 289.60 on FiO₂ of 50%. The patient was extubated 2 days after intubation, which is considered rapid and highly uncommon for patients with COVID-19 pneumonia, and subsequently transferred out of the ICU.

“This case report demonstrates that a well-known procedure of RBCX should be considered in the early management of patients with SCD and COVID-19 to prevent the need for mechanical ventilation and ICU admission due to respiratory distress,” the authors wrote. “RBCX appears to be beneficial not only to the patient’s overall health but also to the healthcare system by reducing cost as well as limiting the use of sparse resources, such as ICU beds and staffing, during a worldwide pandemic.”

Reference

Nguyen V, Alcius P, Peles S, Hodgin K. A fresh breath of oxygen: red blood cell exchange transfusion in sickle cell and COVID-19. Clin Case Rep. 2021;9(8):e04655. doi:10.1002/ccr3.4655