How low should we go: A systematic review and meta-analysis of the impact of restrictive red blood cell transfusion strategies in oncology

Abstract

Background Most non-oncologic clinical practice guidelines recommend restrictive allogeneic blood transfusion practices; however, there is a lack of consensus regarding the best transfusion practice in oncology. We conducted a systematic review of the literature to compare the efficacy and safety of restrictive versus liberal transfusion strategies in patients with cancer. Methods A literature search using MEDLINE, PUBMED and EMBASE identified all controlled studies comparing the use of restrictive with liberal transfusion in adult oncology participants up to August 10, 2015. Two review authors independently assessed studies for inclusion, extracted data and appraised the quality of the included studies. The primary outcomes of interest were blood utilization and all-cause mortality. Results Out of 4241 citations, six studies (3 randomized and 3 non-randomized) involving a total of 983 patients were included in the final review. The clinical context of the studies varied with 3 chemotherapy and 3 surgical studies. The overall risk of bias in all studies was moderate to high. Restrictive transfusion strategies were associated with a 36% reduced risk of receiving a perioperative transfusion (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.49 to 0.83). There was no difference in mortality between the strategies (RR 1.00, 95% CI 0.32 to 3.18). There were no differences in adverse events reported between the restrictive and liberal transfusion strategies. Conclusion Restrictive strategy appears to decrease blood utilization without increasing morbidity or mortality in oncology. This review is limited by a paucity of high quality studies on this topic. Better designed studies are warranted.

Short‐term effect of preoperative intravenous iron therapy in colorectal cancer patients with anemia: results of a cohort study

“…In this regard, the optimal transfusion threshold, dosing, and age of red blood cell (RBC) units have been studied. At present, a restrictive transfusion threshold is recommended for hospitalized adult patients and seems to be safe in the oncologic setting . Moreover, standard‐issue RBC units rather than fresh RBC units (storage length, <10 days) and, to initiate, 1 rather than 2 RBC units are advised .…”

“…At present, a restrictive transfusion threshold is recommended for hospitalized adult patients and seems to be safe in the oncologic setting. 28,29 Moreover, standard-issue RBC units rather than fresh RBC units (storage length, <10 days) and, to initiate, 1 rather than 2 RBC units are advised. 29 Although we corrected our results for the year of treatment, the combined efforts to optimize colorectal cancer care (e.g., centralization, protocols, laparoscopy) might have contributed differently to the results.…”

Outcomes of red blood cell transfusions prescribed in organ donors by the Digital Intern, an electronic decision support algorithm

“…In terms of RBC transfusion, the goal is to achieve a balance between transfusing enough blood to prevent end organ damage and overtransfusing, exposing the patient to unnecessary risks of transfusion including exposure to infectious agents, transfusion reactions, and the possibility of alloimmunization. [1][2][3]7,8 The decision to transfuse is commonly initiated or triggered by Hb or Hct thresholds that have been well-defined over the past decade and are based on evidence in support of restrictive transfusion practices. These recommendations have been formalized in the AABB guidelines and guidelines from other groups.…”

2016 proceedings of the National Heart, Lung, and Blood Institute's scientific priorities in pediatric transfusion medicine

“…What are the physiologic responses, clinical consequences, and optimal use of RBC transfusions in children with anemia due to marrow failure? 30 The fate of transfused RBCs and free non-transferrin-bound iron in patients with primary or treatment-related marrow aplasia may differ from patients with "consumptive" causes including hemorrhage or inflammatory-driven anemia. Recent guidelines encourage measuring iron burden in chronically transfused oncology and transplant patients, but the effects and management of iron overload and its consequences are poorly understood in children with malignancies.…”