New international platelet transfusion guidelines now available

New international platelet transfusion guidelines now available  

The Association for the Advancement of Blood & Biotherapies (AABB) in partnership with the International Collaboration for Transfusion Medicine Guidelines (ICTMG), have published a new set of platelet transfusion guidelines, with practical advice on the appropriate use of platelets in various clinical settings.   

The guidelines are informed by a recent systematic literature review and meta-analysis1. Data from 21 randomised controlled trials (RCTs) and 13 observational studies were examined to compare transfusion strategies using fewer (restrictive) vs greater (liberal) amounts of platelets. The specific definitions of restrictive and liberal varied between trials, with most using platelet count thresholds. Different platelet doses or varying timing of platelet transfusion were used less commonly. 

The panel concluded that the ‘evidence demonstrated that restrictive transfusion strategies probably did not cause increases in mortality or bleeding relative to liberal strategies across predefined clinical populations’. 

The guidelines offer recommendations for platelet transfusion based on specific patient criteria and vary depending on patients’ needs, categorised based on the degree of evidence.  

In summary, the guidelines advocate for a shift toward more restrictive platelet transfusion strategies. The panel noted that the quality of evidence varied substantially across patient populations. In addition, as thrombocytopenic patients have heterogeneous bleeding risk factors, these may not have been captured by inclusion criteria in trials or in the baseline features of the patients enrolled. The panel also highlighted gaps in the evidence base where robust data from RCTs are still lacking including cardiopulmonary bypass, ECMO, and interventional radiology.  

The authors reiterated the importance of clinical judgment and the application of good practice in considering the overall clinical context and alternative therapies when deciding to perform a platelet transfusion. 

These new guidelines provide a foundation for clinical decision making and for future targeted research. They also provide a framework to support initiatives in practice improvement and the sustainable use of platelets, including contingency planning.  

Click here for full article 

Good Practice Statement  

The panel considered it good clinical practice ‘to also consider symptoms, signs, other laboratory parameters, bleeding history, medications, patients’ values and preferences, alternative therapies, and overall clinical context when deciding to perform a platelet transfusion on a particular patient’. 

The panel made the following recommendations:

Strong recommendations and guidance with high or moderate-certainty of evidence* 

1.1 ‘Nonbleeding patients with hypoproliferative thrombocytopenia actively receiving chemotherapy or undergoing allogeneic stem cell transplant (SCT)’ - ‘Platelet transfusion should be administered when the platelet count is < 10 x 10⁹/L’ [*Moderate] 

1.2 ‘Preterm neonates without major bleeding’ - ‘Platelet transfusion should be administered when the platelet count is < 25 x 10⁹/L’ [*High] 

1.3 ‘Patients undergoing lumbar puncture’ - ‘Platelet transfusion should be administered when the platelet count is < 20 x 10⁹/L’ [*Moderate] 

1.4 ‘Patients with Dengue-related consumptive thrombocytopenia in the absence of major bleeding’ - ‘No platelet transfusion’ [*Moderate] 

Conditional recommendations and guidance with lower certainty of evidence^ 

2.1 ‘Non-bleeding adult patients with hypoproliferative thrombocytopenia undergoing autologous SCT or with aplastic anaemia’ - ‘no prophylaxis strategy’ [^Low to very low] 

2.2 ‘Adult patients with consumptive thrombocytopenia due to critical illness (non-Dengue) and without major bleeding’ - ‘Platelet transfusion should be administered when the platelet count is < 10 x 10⁹/L’ [^Very low] 

2.3 ‘Adult patients undergoing central venous catheter (CVC) placement at anatomic sites amendable to manual compression’- ‘Platelet transfusion should be administered when the platelet count is < 10 x 10⁹/L’ [^Moderate to very low] 

2.4 ‘Adult patients undergoing interventional radiology procedures’ - ‘Platelet transfusion should be administered when the platelet count is < 20 x 10⁹/L in low-risk procedures and    < 50 x 10⁹/L for high-risk procedures’ [^Very low] 

2.5 ‘Adult patients undergoing major nonneuraxial surgery’ - ‘Platelet transfusion should be administered when the platelet count is < 50 x 10⁹/L’ [^Very low] 

2.6 ‘Nonthrombocytopenic patients undergoing cardiovascular surgery in the absence of major haemorrhage, including those receiving cardiopulmonary bypass’ - ‘No platelet transfusion’ [^Very low] 

2.7 ‘Adult patients with spontaneous or traumatic, nonoperative intracranial haemorrhage with platelet counts > 100 × 10⁹/L, including those receiving antiplatelet agents’ ‘No platelet transfusion’ [^Low to very low] 

For further information, refer to Table 3 within the guidelines which also includes a summary of the justification for each recommendation.    

Note: ‘Recommendations may not apply to all individual patient scenarios, as noted in the good practice statement, and for conditional recommendations, clinicians should carefully consider the individual patient’s values and preferences in the decision.’ 

References  

1. Jug R, La Rocca U, Al-Riyami AZ, Bathla A, Metcalf RA, White SK, Stanworth SJ, Nahirniak S. The clinical use of platelet transfusions: A systematic literature review and meta-analysis on behalf of the International Collaboration for Transfusion Medicine Guidelines. Transfusion. 2025. 

Additional resources  

Podcast - JAMA Clinical Reviews podcast 

Brought to you by the AABB and the ICTMG 

Author Ryan Metcalf, MD, discusses new clinical guidelines for platelet transfusion and more with JAMA Executive Editor Gregory Curfman, MD.