BLOOD TRANSFUSION SUPPORT AND BLOODLESS ALTERNATIVES IN CHEMOTHERAPY-INDUCED MYELOSUPPRESSION: A LINEAGE-BASED CRITICAL REVIE

Abstract

Chemotherapy-induced myelosuppression produces cytopenias that have traditionally required supportive blood component therapy, but patient preference and transfusion-related risk have driven interest in transfusion-sparing and bloodless alternatives whose safe boundaries remain poorly defined. This critical narrative review synthesises current guideline statements and high-level evidence on transfusion support and transfusion-sparing strategies across the erythroid, megakaryocytic, and granulocytic compartments, and identifies the clinical contexts in which bloodless management is unsafe. Restrictive red-cell thresholds, prophylactic granulocyte colony-stimulating factor (G-CSF), and intravenous iron each have a defensible evidence base, with reported effect sizes drawn from existing meta-analyses (for example, G-CSF and febrile neutropenia, relative risk 0.54; intravenous iron and transfusion, relative risk 0.72). Erythropoiesis-stimulating agents raise haemoglobin but carry a mortality signal and are restricted to non-curative settings. Newer evidence supports more restrictive platelet transfusion thresholds and an emerging role for thrombopoietin receptor agonists in maintaining chemotherapy dose intensity, although the latter is not yet an approved indication. Synthetic oxygen carriers remain experimental in most high-income regulatory settings. Bloodless pathways can reduce transfusion exposure in selected patients, especially where anaemia and neutropenia can be anticipated and treated early, but remain unsafe or high-risk when cytopenias are rapid, profound, haemorrhagic, or complicated by limited physiological reserve. The review's distinct contribution is an integrated, compartment-based account of where bloodless management succeeds and fails, with explicit attention to nursing-led implementation.