Personalized management of platelet transfusion refractoriness: risk factors, cross-matching, and IVIG strategies

Abstract

Background Platelet transfusion refractoriness (PTR) is a major clinical challenge in hematologic patients, yet real-world evidence comparing transfusion strategies—particularly the role of cross-matched platelets and intravenous immunoglobulin (IVIG)—remains limited. Methods We retrospectively analyzed 144 hematologic patients diagnosed with PTR at Nanfang Hospital (2019–2022), totalling 1,345 transfusion episodes. Patients were stratified by platelet antibody status. Four transfusion regimens were compared: random platelets, cross-matched platelets, random platelets + IVIG, and cross-matched platelets + IVIG. The primary endpoint was 24-h corrected count increment (CCI). Logistic regression identified factors associated with antibody development. The primary analysis was performed using linear mixed-effects models (LMMs) with a random intercept for patients to account for within-patient correlation. Fixed effects included transfusion strategy along with prespecified episode-level and patient-level covariates. Generalized estimating equations (GEE) were used as a sensitivity analysis to assess the robustness of the findings. Results Female sex emerged as the strongest independent predictor for the development of platelet antibodies (OR: 4.18, 95% CI: 2.25–8.24). Other univariate risk factors included age, obstetric history, diagnosis, and chemotherapy cycles. Among antibody-positive patients, both cross-matched platelets and IVIG combined with random platelets were associated with improved 24 h CCI compared with random platelets alone (all p Holm < 0.001), cross-matched platelets were associated with higher 24 h CCI relative to random plus IVIG ( p Holm = 0.019), whereas cross-matched platelets plus IVIG demonstrated no additional benefit vs. cross-matched platelets alone in this cohort ( p Holm = 0.444). In antibody-negative patients, no statistically significant difference in 24 h CCI was observed across the four transfusion strategies ( p = 0.244). Consistent with the LMM results, the overall effect of transfusion strategy was not statistically significant among antibody-negative patients ( p = 0.692) but was significant among antibody-positive patients ( p < 0.001). Similar results were obtained using GEE, supporting the robustness of these findings. Conclusion Among patients with antibody-negative PTR, cross-matched platelets and IVIG demonstrated no additional benefit in this cohort. For antibody-positive PTR, cross-matched platelets showed the most favorable response in this cohort; when unavailable, high-dose IVIG with random platelets may be preferentially considered. These comparative treatment findings require prospective validation.

The authors' abstract, as published at the source. Frontiers in Medicine, 2026 · DOI ↗