The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial.
Researchers have compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy.
Researchers have enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy ( transfusion when the hemoglobin level fell below 7 g per decilitre ) and 460 to a liberal strategy ( transfusion when the hemoglobin fell below 9 g per deciliter ).
Randomization was stratified according to the presence or absence of liver cirrhosis.
A total of 225 patients assigned to the restrictive strategy ( 51% ), as compared with 61 assigned to the liberal strategy ( 14% ), did not receive transfusions ( P less than 0.001 ).
The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group ( 95% vs. 91%; hazard ratio for death with restrictive strategy, HR=0.55; P=0.02 ).
Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group ( P=0.01 ), and adverse events occurred in 40% as compared with 48% ( P=0.02 ).
The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer ( HR=0.70 ) and was significantly higher in the subgroup of patients with cirrhosis and Child–Pugh class A or B disease ( HR=0.30 ), but not in those with cirrhosis and Child–Pugh class C disease ( HR=1.04 ).
Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy ( P=0.03 ) but not in those assigned to the restrictive strategy. ( Xagena )
In conclusion, as compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. ( Xagena )
Villanueva C et al, N Engl J Med 2013; 368:11-21