517254

research-article2014
JFM0010.1177/1098612X13517254Journal of Feline Medicine and SurgeryReed et al

Original Article

Journal of Feline Medicine and Surgery

Assessment of five formulae to 2014, Vol. 16(8) 651­–656

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DOI: 10.1177/1098612X13517254

volume in cats jfms.com

Nicki Reed1, Irene Espadas2, Stephanie M Lalor1

and Caroline Kisielewicz3

Abstract
This retrospective study aimed to identify the most accurate formula for estimating the increase in packed cell
volume (PCV) after whole blood transfusion of cats, as several formulae have been reported but not validated.
Forty cats, of varying breeds and gender, were included from two referral institutions after database searches
over a 13 year period. Five formulae were used to calculate an estimated post-transfusion PCV based on the
re-working of formulae for determining the volume of donor blood to be transfused; three formulae were derived
from those previously reported in the feline literature and two from human paediatric medicine, where a similar
mean blood volume has been described. Cats were subdivided into two groups, the first consisting of 17 cats
with non-regenerative anaemia and the second consisting of 23 cats with ongoing losses such as haemolysis and
haemorrhage; it was hypothesised that formulae could be more accurate for group 1 cats, whereas formulae applied
to group 2 cats could have overestimated the post-transfusion PCV. Bland–Altman analysis was performed for all
cats to compare the actual increase in PCV with the calculated increase for the five formulae. Formula 1 (PCV %
increase = volume of blood transfused in ml/2 × bodyweight in kg) performed best overall and is easy to calculate;
however, no single formula was highly accurate at predicting the PCV increase after whole blood transfusion in cats
and, owing to the wide confidence intervals, these formulae should be applied judiciously in the clinical setting.

Accepted: 25 November 2013

Introduction An accurate formula to estimate expected post-trans-

In the UK, feline blood transfusions are not routinely
undertaken in practice as feline blood products are not
commercially available and blood donor availability can
be limited. Anaemia therefore represents a frequent rea-
son for referral to specialist centres for blood transfu-
sions to be performed.
Published transfusion formulae could be used to esti-
mate the required volume of blood to reach a specified
post-transfusion packed cell volume (PCV). However, as
the volume of blood administered to feline recipients is
often dictated by the volume obtained from the donor,
these formulae are usually re-worked to estimate the
expected post-transfusion PCV. Formulae are frequently
based on the transfusion of packed red blood cells (pRBC)
fusion PCV could enable ongoing losses from haemoly-
sis or haemorrhage to be more readily identified, as the
post-transfusion PCV would be lower than expected.
The aim of this retrospective study was to identify the
most appropriate formula to use for estimating the post-
transfusion PCV, with the hypotheses that current for-
mulae used to predict the increase in PCV after blood
transfusion tend to overestimate the expected value and
that a formula incorporating the donor’s PCV could be
more accurate than one that does not.
1Royal(Dick) School of Veterinary Studies, University of
Edinburgh, Easter Bush, Edinburgh, UK
2School of Veterinary Medicine, Glasgow, UK

or canine whole blood (WB), with a higher PCV than is 3Royal Veterinary College, Hatfield, UK

typical for cats, and might therefore not be appropriate for

Corresponding author:
feline transfusion.1–5 Formulae that include the donor PCV Caroline Kisielewicz MVB, CertSAM, MRCVS, Royal Veterinary
and volume of blood transfused might be expected to be College, Hawkshead Lane, North Mymms, Hatfield, AL9 7TA, UK
more accurate, as was identified recently in a canine study.6 Email: carkis13@yahoo.com
652 Journal of Feline Medicine and Surgery 16(8)

Materials and methods smear examination findings of an experienced clinical

Computerised databases at the University of Edinburgh
Hospital for Small Animals (HFSA) and the University
of Glasgow Small Animal Hospital (SAH) were searched
for cats that had received WB transfusions between 1
January 2000 and 31 January 2013. These transfusions
involved the collection and administration of fresh WB
and were performed with a similar approach at both
sites. Donor cats were acquired from registers of staff
and client-owned cats between the age of 1 and 8 years.
Donor cats were blood-typed and only type-compatible
blood was administered to recipients. Blood was col-
lected into 10 ml syringes containing citrate–phosphate–
dextrose–adenine anticoagulant at a ratio of 1:9 with
blood. A minimum donation volume of 10 ml/kg was
aimed for, although, on occasion, this was not achieved
owing to inadequate donor compliance.
Case records of transfusion recipients were retrieved
and searched for patient signalment, weight, blood type
(A, B or AB), cause of anaemia, pre- and post-transfusion
PCV, volume of blood transfused (VT), donor PCV and
transfusion duration. The cats were classified into two
groups: group 1 comprised cats with non-regenerative
anaemia that were unlikely to have acute changes in
PCV; group 2 cats had ongoing blood loss from haemoly-
sis or haemorrhage that might lead to a sub-optimal
response to transfusion. Regeneration was defined as an
appropriate reticulocyte count in the presence of severe
anaemia or was determined by the blood
pathologist. Attributing haemolysis as the cause of
regenerative anaemia was based on a combination of
findings, including the presence of red-coloured serum,
icteric serum when hepatic and post-hepatic causes were
excluded, positive in-saline agglutination or Coombs
test results, and the lack of haemorrhage. The actual
change in PCV (ΔPCV) was calculated by subtracting the
pre-transfusion from the post-transfusion PCV.
Cases were excluded if any of the above data were
missing, or if a PCV had not been performed within 12 h
of the end of the transfusion; this time limit was arbitrar-
ily chosen to ensure that ongoing blood loss would not
excessively affect the post-transfusion PCV. Only the
first transfusion, of cats receiving multiple transfusions,
was included to exclude possible confounding factors
such as delayed transfusion reactions.
Five formulae (Table 1) were used to calculate the
expected increase in PCV for all cats. The first three for-
mulae were derived from formulae published in the vet-
erinary literature,5,7,8 whereas the fourth and fifth
formulae were derived from formulae published in
human paediatric literature.9,10
Statistical analyses were performed using the com-
mercial statistical package, Minitab 16. Descriptive sta-
tistics were performed for the whole population, and
numbers were reported for categorical data. Quantitative
data were assessed for normality using the Anderson–
Darling test and summarised as mean (± SD) or median

Table 1  Formulae used to calculate expected packed cell volume (PCV) (%) post-transfusion and their derivations

Formula Mathematical derivation Formula used for calculation of

post-transfusion PCV

Formula 17 VT = desired PCV (%) increase (Δ1) × 2 × BW (kg) Δ1 PCV (%) = VT (ml)
       2 × BW (kg)
Formula 28 VT = desired PCV (%) increase (Δ2) × 1.7 × BW (kg) Δ2 PCV (%) = VT (ml)
       1.7 × BW (kg)
Formula 35 VT = BW (kg) × 60 × (desired PCV [%] – current PCV [%])/ Δ3 PCV (%) = VT (ml) × donor blood PCV (%)
donor blood PCV,        60 × BW (kg)
desired PCV (%) increase (Δ3)/donor blood PCV =
VT/60 × BW (kg)
Formula 49 pRBC volume (ml) = 1.6 × BW (kg) × desired PCV (%) Δ4 PCV (%) = VT (ml)
increase,        3 × BW (kg)
desired PCV (%) increase (Δ4) = pRBC volume (ml)/
1.6 × BW (kg),
average pRBC PCV = 70%; factor of 1.6 × 1.9 (= 3.04) to
accommodate average feline WB PCV of 37%
Formula 510 pRBC volume (ml) = BW (kg) × ΔHb × 3/(donor blood PCV Δ5 PCV (%) = VT (ml) × donor blood PCV (%)
[%]/100),        100 × BW (kg)
(pRBC volume [ml] × donor blood PCV [%])/(3 × 100 × BW
[kg]) = ΔHb,
as ΔHb approximates to 1/3 ΔPCV,
desired PCV (%) increase (Δ5) = (3 × VT [ml] × donor blood
PCV)/(3 × 100 × BW [kg])

VT = volume of donor blood transfused; BW = body weight; pRBC = packed red blood cells; WB = whole blood; Hb = haemoglobin
Reed et al 653

(range) as appropriate. Parametric data were compared
by means of Student’s t-test to assess for differences
between groups 1 and 2, whereas the Mann–Whitney
U-test was used to compare non-parametric data. P val-
ues <0.05 were considered significant. Bland–Altman
analysis was performed to compare the five formulae
used to calculate the expected increase in PCV for the
whole population, and then group 1 and group 2 cats
separately. Bias was determined as the mean difference
between the calculated increase and the actual increase.
Limits of agreements (LOA) were determined by calcu-
lating mean ± 1.96 SD and indicated the 95% confidence
intervals.
Results
The database search identified 49 feline blood transfu-
sions from HFSA and 20 from SAH. Twenty-nine cases
were subsequently excluded, leaving 40 transfusions in
the study population. Two cats had received a second
transfusion 5 and 7 days after the initial transfusion;
only the data from the first transfusions were used. The
remaining 27 cases were excluded as donor PCV had
not been recorded; however, some cases had more than
one reason for exclusion, including failure to measure
post-transfusion PCV within 12 h (n = 9), failure to
record VT (n = 3) or failure to record bodyweight (n = 2).
Descriptive data of the 40 cats included are given in
Table 2.
Group 1 comprised 17 cats with non-regenerative
anaemia due to bone marrow disorders (n = 10), such as
myelodysplasia, bone marrow precursor immune-medi-
ated haemolytic anaemia and aplastic anaemia; systemic
neoplasia with or without bone marrow involvement
(n = 5), such as lymphoma and disseminated histiocytic
sarcoma and inflammatory or chronic disease (n = 4);
chronic hepatopathy; and feline infectious peritonitis.
Group 2 comprised 23 cats with ongoing blood loss due
to immune-mediated haemolytic anaemia (n = 15),

Table 2  Descriptive data of the study population; results are reported as mean (± SD) or median (range) as appropriate

Variable All cats Group 1 Group 2

Number of cats 40 17 23
Breed DSH (n = 30) DSH (n = 12) DSH (n = 18)
MC (n = 3) MC (n = 2) DLH (n = 2)
DLH (n = 2) BSH (n = 1) MC (n = 1)
BSH (n = 1) Oriental (n = 1) Persian (n = 1)
Persian (n = 1) Ragdoll (n = 1) Ocicat (n = 1)
Oriental (n = 1)
Ragdoll (n = 1)
Ocicat (n = 1)
Sex MN (n = 20) MN (n = 10) MN (n = 10)
ME (n = 2) ME (n = 1) ME (n = 1)
FN (n = 17) FN (n = 6) FN (n = 11)
FE (n = 1) FE (n = 1)
Age (years) 3.0 (0.5–17.0) 3.0 (0.7–17.0) 2.8 (0.5–15.1)
Weight (kg) 3.9 (± 1.3) 4.1 (± 1.6) 3.8 (± 1.1)
Blood type A n = 34 n = 14 n = 20
Blood type B n=6 n=3 n=3

DSH = domestic shorthair; MC = Maine Coon; DLH = domestic longhair; BSH = British shorthair; MN = male neutered; ME = male entire;
FN = female neutered; FE = female entire

Table 3  Blood transfusion data for the study population with statistical comparisons between groups 1 and 2; results
reported as mean (± SD) or median (range) as appropriate

Variable All cats Group 1 Group 2 P

Number of cats 40 17 23 –
Pre-transfusion PCV (%) 9.7 (± 3.5) 9.4 (± 3.0) 10.0 (± 3.9) 0.58
Post-transfusion PCV (%) 15.7 (± 4.6) 15.7 (± 4.9) 15.7 (± 4.6) 0.99
Increase in PCV (%) 6.0 (± 3.8) 6.3 (± 4.4) 5.7 (± 3.3) 0.77
Donor PCV (%) 38.8 (± 4.7) 37.2 (± 5.5) 40.0 (± 3.8) 0.57
Volume of blood transfused (ml) 49 (15–61) 41 (20–61) 50 (15–60) 0.36
Duration of transfusion (h) 3.5 (± 1.4) 3.7 (± 1.6) 3.4 (± 1.2) 0.56

PCV = packed cell volume

654 Journal of Feline Medicine and Surgery 16(8)

Table 4  Results of Bland–Altman analysis for formulae 1–5

10

Formula Case Bias (%) LOA (± 1.96 SD)

Difference in PCV (calculated

ULA = 7.20
categorisation 5

PCV – actual PCV) %

1 All cats –0.35 7.2, –7.91
0 Mean = –0.35
Group 1 0.44 8.29, –7.41
Group 2 –0.94 6.35, –8.23
–5
2 All cats –1.41 6.69, –9.52
LLA = –7.91
Group 1 –0.46 7.66, –8.58
–10
Group 2 –2.12 5.87, –10.11
2 4 6 8 10 12 14
3 All cats –2.24 6.6, –11.08 Average PCV [(calculated PCV + actual PCV)/2] %
Group 1 –0.91 7.28, –9.11
Group 2 –3.22 5.75, –12.19
4 All cats 1.71 8.05, –5.08 Figure 1  Bland–Altman plot for formula 1 applied to all 40
cats; the central horizontal line, or mean, represents the
Group 1 2.29 9.7, –5.12
average agreement of the data or bias, and the other two
Group 2 1.29 7.63, –5.05
horizontal lines, upper limit of agreement (ULA) and lower
5 All cats 1.00 8.05, –6.05 limit of agreement (LLA), represent the 95% confidence
Group 1 1.85 9.22, –9.82 intervals. PCV = packed cell volume
Group 2 0.36 7.06, –6.33

LOA = limits of agreement

10.0
Difference in PCV (calculated

7.5
ULA = 7.06
PCV – actual PCV) %

5.0
10
ULA = 8.29 2.5
Difference in PCV (calculated

0.0 Mean = 0.36

PCV – actual PCV) %

5
–2.5

Mean = 0.44 –5.0

0
LLA = –6.33

2 4 6 8 10 12
–5 Average PCV [(calculated PCV + actual PCV)/2] %

LLA = –7.41

2 3 4 5 6 7 8 9 Figure 3  Bland–Altman plot for formula 5 applied

Average PCV [(calculated PCV + actual PCV)/2] %
to group 2 cats; the central horizontal line, or mean,
represents the average agreement of the data or
bias, and the other two horizontal lines, upper limit of
Figure 2  Bland–Altman plot for formula 1 applied to group agreement (ULA) and lower limit of agreement (LLA),
1 cats; the central horizontal line, or mean, represents the represent the 95% confidence intervals. PCV = packed
average agreement of the data or bias, and the other two cell volume
horizontal lines, upper limit of agreement (ULA) and lower limit
of agreement (LLA), represent the 95% confidence intervals.
PCV = packed cell volume difference (P = 0.77) in the mean increase in PCV was
found between group 1 (6.35%) and group 2 (5.74%) cats.
Results for the Bland–Altman analyses for the five for-
sepsis/disseminated intravascular coagulopathy (n = 5) mulae (Table 4) show that the formula with the lowest
or blood loss (n = 3). bias value for all 40 cats was formula 1 (Figure 1). Formula
PCV was measured within 1 h of transfusion in all cases 1 also showed a low bias for group 1 cats (Figure 2).
except for five; these were assessed within 12 h. The Formula 5 resulted in the lowest bias for group 2 cats
method of PCV assessment (micro-haematocrit tube cen- (Figure 3).
trifugation or haematocrit) was not recorded in most cases.
Transfusion duration was not recorded in nine cases, but Discussion
these were not excluded as this was not a primary aim of There are three formulae to estimate post-transfusion
the study. Transfusion data are given in Table 3. PCV commonly used in feline veterinary practice (for-
There was no statistical difference between groups 1 mulae 1–3);5,7,8 however, to our knowledge there have
and 2 for age (P = 0.92), weight (P = 0.40) or other trans- been no previous studies to compare their accuracy. In
fusion variables as depicted in Table 3. No significant canine transfusion medicine, several formulae also exist,
Reed et al 655
which could reflect a lack of superiority of one formula
over another.2–6,11 This is similar to the situation in human
paediatric medicine, where several formulae are applied
without having been clinically validated.9
The hypothesis that commonly used veterinary for-
mulae over-estimate the PCV actually attained post-
transfusion was not supported. Although the
Bland–Altman calculations identified low bias for some
formulae, this merely reflected that cases where the PCV
was over-estimated were balanced by cases where the
PCV was underestimated, and this was consistent for
both patients with non-regenerative anaemia and those
with ongoing haemorrhage or haemolysis.
Cats were divided into two sub-populations as the
formula applied to group 1 cats had the potential to be
more accurate than when applied to group 2 cats in
which ongoing losses were expected. Although the bias
for formula 1 was low, the LOA could be considered
quite wide for the clinical situation, with cats achieving
7–8% less or more than the calculated PCV. The bias and
limits of agreement were larger for group 2 cats, where
ongoing losses could account for lower values than pre-
dicted, and a marked regenerative response combined
with termination of blood losses could account for higher
values than predicted.
Formula 1 has previously been used in a study evalu-
ating outcomes of feline WB transfusions.12 Although
Bland–Altman analysis was not performed in that study,
the outcomes reported for use of this formula appear
similar, in that the difference between the calculated and
actual PCV obtained was −7.8 to 12.4% for cats with inef-
fective erythropoiesis, and −5.9 to 6.0% in cats with
haemolytic anaemia, which is similar to the values
obtained in the current study.
A formula that incorporates the PCV of the blood
donor might be expected to be more accurate in predict-
ing the post-transfusion PCV than a formula that does
not, as was suggested in a recent canine study.6 This
hypothesis was not supported, however, with both a
larger bias and wider LOA for formula 3 compared to
formula 1, suggesting that an optimal formula is lacking
at present. The denominator of 60 used in this formula is
derived from the estimated feline blood volume,5,13 with
this figure being replaced by 85 or 90 in the canine for-
mula.5,6 This might not reflect the situation in feline
transfusion patients that could be volume expanded,
either from intravenous fluid therapy received prior to
transfusion or from the transfusion itself in normovolae-
mic anaemic patients.
Veterinary formulae based on volume of pRBC
transfused, without taking into account the PCV of the
pRBC, were not considered likely to be useful in feline
WB transfusions owing to the large difference in PCV
of these components. Formulae from the human pae-
diatric literature were therefore explored as these are
calculated on a weight basis; the VT in adults is based
on units of blood. In addition, neonates have been
reported to have a mean blood volume of 70 ml/kg,
similar to cats.9 The human formulae did not, how-
ever, prove to be superior to formulae already availa-
ble for cats.
Ideally, an accurate formula would allow identifi-
cation of ongoing losses in patients that do not achieve
the predicted rise in PCV. It was not possible to do
this, and it was unexpected that the mean increase in
PCV for group 2 cats was not statistically different
from those in group 1. Cats in both groups attained
higher and lower PCVs than predicted. Lower-than-
predicted PCVs could be the result of unrecognised
haemorrhage or haemolysis (eg, from a transfusion
reaction), volume expansion through fluid therapy or
laboratory error. Higher-than-predicted PCVs could
be the result of a marked regenerative response, obe-
sity leading to overestimation of recipient’s lean body
weight or laboratory error. Sources of laboratory error
could include under- or over-filling of the blood tube,
inappropriate centrifugation of the micro-haematocrit
tube (speed and duration) and variation in the tech-
nique used.
A limitation of this study is that the method used to
assess the PCV was rarely recorded. It is possible that
some cases had pre- and post-transfusion samples meas-
ured by different techniques (centrifugation of a micro-
haematocrit tube or calculation of haematocrit from
erythrocyte count and mean corpuscular volume), which
could have led to errors.
Another limitation of the study is that PCV measure-
ments were not taken at a consistent time after transfu-
sion. One study in children suggested that there is little
change in the haemoglobin value 1 and 7 h after transfu-
sion,10 whereas another study in neonates suggested that
an accurate measurement can be obtained 15 mins after
the end of the transfusion.14 It is possible, however, that
this might not be directly comparable to veterinary
patients, as the potential for volume overload could be
greater with WB administered to cats compared with
pRBC transfusions administered to humans. As such,
the PCV might not have attained its maximal value
within the 12 h time-frame chosen for this study owing
to ongoing removal of fluid from the vascular space.
Patients could also have been volume-expanded as a
result of prior fluid therapy, as this was not taken into
account.
The small number of cases after exclusion is a further
limitation, and that is why it was felt useful to evaluate
the population as a whole, in addition to sub-dividing
the population. However, it is the first study, to our
knowledge, that has examined the accuracy of predict-
ing response to whole blood transfusions in cats. Ideally,
a prospective study should be performed in order that
656 Journal of Feline Medicine and Surgery 16(8)
methodology and timing of PCV measurement is stand-
ardised and fluid therapy taken into account in inclusion
criteria, which could allow a more accurate formula to be
identified for predicting post-transfusion PCV.
Conclusions
No single formula was identified as being highly accu-
rate at predicting the post-transfusion PCV in anaemic
cats. Overall, formula 1 performed best, with low bias
across groups, in addition to being easy to use. However,
the actual PCV attained post-transfusion could be up to
8% more or less than expected.
Conflict of interest  The authors do not have any potential
conflicts of interest to declare.
Funding  This research received no grant from any funding
agency in the public, commercial or not-for-profit sectors.
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