A randomized trial among patients suffering from acute upper gastrointestinal bleeding, was published in The New England Journal of Medicine. Findings suggest that a strategy of restrictive red cell transfusion may result in better outcomes than a strategy of liberal transfusion.
Dr. Loren Laine, a Yale University physician who authored an editorial on the trial, stated:
“Previous large randomized clinical trials have largely ruled out that liberal transfusion strategy is better that a restrictive transfusion strategy. But these trials didn’t show a significant benefit to the restrictive transfusion strategy in important clinical outcomes like 30 day mortality. Also, these studies didn’t include patients with acute GI bleeding, so they may not be generalizable to patients with GI bleeding.”
This most recent clinical trial, led by Dr. Càndid Villanueva, enrolled 961 patients with severe GI bleeding. Half of the patients were assigned to a restrictive strategy, defined by transfusions occurring only when hemoglobin levels were below 7 grams per deciliter. The other half of the patients were assigned to a liberal strategy, which was defined by transfusions occurring when hemoglobin levels were below 9 grams per deciliter.
The trial showed that the restrictive strategy was associated with decreased additional bleeding, shortened hospital stay and fewer adverse events.
Dr. Laine further noted this:
“The restrictive strategy was associated with a 45% relative risk reduction in mortality as compared to the liberal strategy and the number needed to treat was 25. This means that 25 patients would have to be treated with the restrictive transfusion strategy rather than the liberal strategy to overt one additional death at 45 days.”
The decreased mortality observed among patients receiving restrictive transfusions was driven by fewer deaths from uncontrollable bleeding.
Here is what Dr. Villanueva stated:
“We conclude with this study, we can save more resources and improve the outcome of patients using this restrictive transfusion strategy for patients with acute gastrointestinal bleeding.”
These new trial results are consistent with the recently released AABB red blood cell transfusion guidelines that favor restrictive transfusion. However, studies have not evaluated all patient populations, and transfusion decisions need to account for the specific symptoms and hemoglobin levels of each patient.
We’ll be back on February 15th with another edition of Transfusion News. Thanks for joining us.
References
1. Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santalo M, Muniz E, Guarner C. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013;368: 11-21.
2. Laine L. Blood transfusion for gastrointestinal bleeding. N Engl J Med 2013;368: 75-6.
3. Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AA, Weinstein R, Swinton McLaughlin LG, Djulbegovic B. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB*. Ann Intern Med 2012;157: 49-58.
