The impact of red blood cell transfusion practices on inpatient mortality in variceal and non‐variceal gastrointestinal bleeding patients: a 20‐year US nationwide retrospective analysis

Abstract

Summary Background Previous studies in upper gastrointestinal (GI) bleeding have reported inconsistent outcomes about packed red blood cell (PRBC) transfusion practices. Aim To assess whether PRBC transfusion is more likely to be dangerous in variceal bleeding than in non‐variceal bleeding due to concern of over‐transfusion leading to elevated portal pressure. Methods We used the Nationwide Inpatient Sample (1999–2018). We identified patients with upper GI bleeding using an algorithmic approach, categorising bleeding from non‐variceal or variceal sources. Our primary outcome was all‐cause inpatient mortality. To control for the severity of bleeding, we performed propensity matching of baseline features, including age, gender, the presence of shock, the need for ICU care and co‐morbidities. We also examined PRBC transfusion, inpatient mortality and hospitalisation rates for both populations. Results We included 10,228,524 upper GI bleeding discharges; 755,135 patients had variceal bleeding. After propensity matching, PRBC transfusion in variceal bleeders was associated with a 22% increase in inpatient mortality, whereas non‐variceal bleeders had a 9% increase in inpatient mortality. Compared to non‐variceal bleeders receiving blood transfusion, variceal bleeders had nearly four‐fold higher odds of inpatient mortality (propensity‐matched OR: 3.8; 95% CI: 3.7–3.8; p < 0.001). Notably, PRBC transfusion rates in both groups have declined since 2011, although it has remained higher in variceal bleeders. Mortality for upper GI bleeding has been declining since 1999. Conclusions Although decreased over the last decade, PRBC transfusion rates remain high for variceal bleeders. In addition, PRBC transfusion appears to be more detrimental in variceal bleeders than in non‐variceal bleeders.

Editorial: the impact of red blood cell transfusion on inpatient mortality in upper gastrointestinal bleeding—authors’ reply

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We thank Drs Orpen-Palmer and Stanley for their thoughtful comments about our work on the impact of red blood cell transfusion on inpatient mortality in variceal and non-variceal upper GI bleeding. 1,2 We agree with the conclusion that clinical judgement is critical in the use of red blood cell transfusion in patients with upper GI bleeding. However, we were somewhat surprised that the effect was limited mainly to variceal upper GI bleedingalthough careful analysis of the available literature aligns with this conclusion.

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“…We thank Drs Orpen‐Palmer and Stanley for their thoughtful comments about our work on the impact of red blood cell transfusion on inpatient mortality in variceal and non‐variceal upper GI bleeding 1,2 . We agree with the conclusion that clinical judgement is critical in the use of red blood cell transfusion in patients with upper GI bleeding.…”

Editorial: the impact of red blood cell transfusion on inpatient mortality in upper gastrointestinal bleeding

“…Radadiya et al have undertaken a cohort study from a database of over 1000 hospitals across the United States over a 20-year period. 6 They included 10,228,54 patients with UGIB of whom 755,135 had a variceal bleed. Following a peak in 2011, the authors found a gradual reduction in the use of PRBC for UGIB.…”

Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease

“…Variceal bleeding is very common in this group of patients and is one of the main drivers of ESLD-associated allogeneic blood transfusions [ 30 ]. Recently it has been demonstrated that allogeneic RBC transfusions are associated with higher mortality in patients with variceal bleeding compared to other bleeding patients [ 31 ]. In addition to pharmacological interventions that influence portal perfusion pressure, such as terlipressin, somatostatin, or octreotide, coagulation factors have a major role in the treatment of variceal bleeding.…”