Outcomes of restrictive versus liberal transfusion strategies in older adults from nine randomised controlled trials: a systematic review and meta-analysis

Simon, Geoff; Craswell, Alison; Thom, Ogilvie; Fung, Yoke Lin

doi:10.1016/s2352-3026(17)30141-2

Cited by 90 publications

(76 citation statements)

References 32 publications

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“…The meta‐analysis found that 30‐day mortality (RR: 1·36; 95% CI: 1·05‐1·74, P = 0·017, n = 4969), 90‐day mortality (RR: 1·45; 95% CI: 1·05‐1·98, P = 0·022, n = 2287) and cardiac outcomes (RR = 1·62 95% CI: 1·12‐2·35, P = 0·010, n = 1367) favoured higher transfusion Hb thresholds across these nine RCTs . When subgroup analysis of only the studies that recruited patients aged ≥65 years was performed, it showed a stronger bias towards higher Hb thresholds for 30‐day mortality (RR: 2·07, 95% CI: 1·09–3·92, P = 0·03).…”

Section: Evidence Specific To Transfusion Of Older Adultsmentioning

confidence: 97%

“…Studies conducted in various countries have identified that older adults consume >50% of the blood supply [4][5][6]. We recently undertook a systematic review and found Correspondence: Geoff Simon, University of the Sunshine Coast, School of Health and Sport Sciences, Health Tower (Building T), Locked Bag 4, Maroochydore, DC 4558, Australia E-mail: gsimon@usc.edu.au only three randomized controlled trials (RCT) comparing restrictive and liberal transfusion strategies in patients aged ≥65 years [7], henceforth described as 'older adults'. It has been shown that both anaemia and transfusion may be associated with worse outcomes in this cohort [8].…”

Section: Introductionmentioning

confidence: 99%

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Questioning the benefit of restrictive transfusion practice in older adults

Simon

Craswell

Thom

et al. 2018

ISBT Science Series

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Restrictive transfusion practice is widely promoted, with many international guidelines recommending haemoglobin thresholds of 70 to 80 g/l for adult patients who are asymptomatic. Randomized controlled trials comparing outcomes associated with liberal and restrictive transfusion strategies underpin this approach. Meta‐analyses including trials of adult patients >18 years of age have concluded that restrictive practice is noninferior to liberal transfusion approaches. A restrictive approach to transfusion reduces resource consumption and cost, as well as the hazards associated with unnecessary exposure to blood products. Although adults aged ≥65 years consume over half of the blood supply, there are few randomized controlled transfusion trials exclusive to this cohort. Our 2017 meta‐analysis of a small number of trials focussed on older adults found that higher transfusion haemoglobin thresholds were associated with lower mortality and fewer cardiac complications in this age group. Other studies have also shown that higher transfusion haemoglobin thresholds are beneficial in older adults. This paper presents recent evidence regarding transfusion outcomes in older adults and discusses aspects of the pathophysiology of ageing that impact on the reduced resilience of older patients to anaemic states. This evidence challenges the use of Hb thresholds that apply across the adult lifespan, regardless of age. It proposes that older age be considered as a risk factor in assessing transfusion requirements, and that transfusion practice in older adults may require higher haemoglobin thresholds than for younger adults.

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Section: Evidence Specific To Transfusion Of Older Adultsmentioning

confidence: 97%

Section: Introductionmentioning

confidence: 99%

Questioning the benefit of restrictive transfusion practice in older adults

Simon

Craswell

Thom

et al. 2018

ISBT Science Series

Self Cite

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show abstract

“…A concern regarding a lower Hb threshold for RBC transfusion in elderly patients has been raised in a recent post‐hoc analysis of the Transfusion Requirements after Cardiac Surgery (TRACS) trial and in a systematic review . Both, however, preceded the Transfusion Requirements in Cardiac Surgery (TRICS‐3) trial, in which a lower Hb threshold was associated with decreased risk of occurrence of a composite outcome of death at day 28, non‐fatal myocardial infarction, stroke and new‐onset renal failure in patients ≥75 years ( P = .004 for interaction, unadjusted OR: 0.70, 95% CI: 0.54‐0.89) .…”

Section: Discussionmentioning

confidence: 99%

“…On the right side, the odds ratios (OR) with corresponding 95% confidence intervals (95% CI) and P-values for the test of interaction is presented for primary analysis (upper row) adjusting intervention effect for patient age only, and in the sensitivity analysis (lower row, denoted with *) adjusting for patient age, haematological malignancy status, site of enrolment and Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score A concern regarding a lower Hb threshold for RBC transfusion in elderly patients has been raised in a recent post-hoc analysis of the Transfusion Requirements after Cardiac Surgery (TRACS) trial and in a systematic review. 16,29 Both, however, preceded the Transfusion…”

Section: F I G U R Ementioning

confidence: 99%

“…15 However, some recent trials have suggested heterogeneous treatment effects among certain patient groups, 4,9,14 and a potential interaction between Hb thresholds for RBC transfusion and patient age. 4,13,16 Background: Use of a lower haemoglobin (Hb) threshold to guide red blood cell (RBC) transfusion is now generally recommended in critically ill patients, but uncertainty remains regarding the optimal Hb threshold for RBC transfusion in patients of different ages.…”

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confidence: 99%

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Heterogenous treatment effects of transfusion thresholds by patient age: Post‐hoc analysis of the TRISS trial

Jonsson

Granholm

Rygård

et al. 2020

Acta Anaesthesiol Scand

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Background Use of a lower haemoglobin (Hb) threshold to guide red blood cell (RBC) transfusion is now generally recommended in critically ill patients, but uncertainty remains regarding the optimal Hb threshold for RBC transfusion in patients of different ages. Methods We conducted a post‐hoc analysis of 998 patients with septic shock and anaemia randomised to RBC transfusion at a Hb threshold of 7 g/dl [4.3 mmol/l] vs 9 g/dl [5.6 mmol/l] in the Transfusion Requirements in Septic Shock (TRISS) trial. We assessed if there were heterogeneous effects between the allocated Hb threshold and patient age categorised and on the continuous scale. The primary outcome was 1‐year mortality; the secondary outcome was 90‐day mortality. Both outcomes were analysed using logistic regression models and in sensitivity analyses with additional adjusting for site of enrolment, presence of haematological malignancy and the Sequential Organ Failure Assessment (SOFA) score. The secondary analyses were Kaplan‐Meier curves with corresponding log‐rank tests. Results We found no heterogeneity between patient age and the allocated Hb thresholds for RBC transfusion for 1‐year mortality or 90‐day mortality in the primary analyses. The sensitivity analyses suggested heterogeneity between age groups regarding 90‐day mortality, however, this was not consistent for 1‐year mortality or when assessing age on the continuous scale. Conclusion In this post‐hoc study of ICU patients with septic shock, we found no reliable heterogeneous effects of transfusion at a Hb threshold of 7 vs 9 g/dl according to patient age on mortality. However, due to low power, this study should only be considered as hypothesis generating.

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Blood Management for the Geriatric Patient

Vera-Arroyo

Zack-Guasp

2021

Essentials of Blood Product Management in Anesthesia Practice

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Outcomes of restrictive versus liberal transfusion strategies in older adults from nine randomised controlled trials: a systematic review and meta-analysis

Cited by 90 publications

References 32 publications

Questioning the benefit of restrictive transfusion practice in older adults

Questioning the benefit of restrictive transfusion practice in older adults

Heterogenous treatment effects of transfusion thresholds by patient age: Post‐hoc analysis of the TRISS trial

Blood Management for the Geriatric Patient

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