Introduction
Gastrointestinal bleeding is among the most common indications for red blood cell (RBC) transfusion. According to current guidelines, restrictive RBC transfusion initiated at a lower haemoglobin (Hgb) level (<70-80 g/L) is non-inferior to liberal strategy (<90-100 g/L) regarding mortality and rebleeding. Moreover, it results in a lower rate of adverse events and decreases hospital expenses. However, the published randomised controlled trials are not using a unified definition for the restrictive modality.
Aims & Methods
Our analysis aims to assess the efficacy of restrictive transfusion by comparing different Hgb thresholds. Patients enrolled in the Hungarian Gastrointestinal Bleeding Registry who received RBC transfusion during hospitalisation were found eligible. The transfused group was divided into subgroups based on their lowest Hgb level during hospitalisation: ≤60 g/L (group 1), 61-70 g/L (group 2), 71-80 g/L (group 3), ≥80 g/L (group 4). Patients with recurrent bleeding were excluded. The outcomes examined included in-hospital mortality, the need for surgical intervention, intensive care therapy, and length of hospital stay. When comparing the groups, group 2 was used as the reference. Adjusted odds ratios (aOR) were calculated using binominal logistic regression, while the ANOVA test was used to determine adjusted mean differences (MD) and the related 95% confidence intervals (CI). The multivariate model included age >65 years, sex, ischemic heart disease, vascular disease, heart failure, chronic obstructive pulmonary disease, active malignancy, antithrombotic and anticoagulant treatment.
Results
Of 1019 patients with gastrointestinal bleeding, 575 (56.42%) were eligible for analysis. The lowest mortality rate was observed in group 3 (8.98%). However, there was no statistically significant difference in mortality odds when comparing transfusion at different Hgb levels to group 2 (1 vs 2: aOR: 0.64, CI: 0.24-1.70; 3 vs 2: aOR: 0.79, CI: 0.27-2.27; 2 vs 4: aOR: 0.50, CI: 0.10-2.48). Group 2 had the slightest need for surgical intervention (2.30%) compared to other groups. There was a tendency towards increased odds of surgical intervention in group 1 compared to group 2 (aOR: 4.13, CI: 0.64-26.65). Furthermore, the odds of intensive care therapy were significantly increased in groups 1 and 4 compared to group 2 (1 vs 2: aOR: 6.37, CI: 1.37-29.53; 4 vs 2: aOR: 10.97, CI: 1.91-62.98). Compared to group 2, group 3 showed an increased tendency in the odds for intensive care unit admission (aOR: 4.83, CI: 0.97-24.07). There was no significant difference in the length of hospital stay among the groups.
Conclusion
Our findings support that haemoglobin levels between 61-70 g/L may be considered safe compared to lower (≤60 g/L) or higher (≥80 g/L) transfusion thresholds. Randomised controlled trials with extended follow-up periods are needed to validate our results.