Outcomes following restrictive or liberal red blood cell transfusion in patients with lower gastrointestinal bleeding

Abstract

Background:Restrictive red blood cell (RBC) transfusion reduces mortality and rebleeding after upper gastrointestinal bleeding (UGIB). However, there is no evidence to guide transfusion strategies in lower gastrointestinal bleeding (LGIB). Aim: To assess the association between RBC transfusion strategies and outcomes in patients with LGIBMethods: This was a post hoc analysis of the UK National Comparative Audit ofLGIB and the Use of Blood. The relationships between liberal RBC transfusion and clinical outcomes of rebleeding, mortality and a composite outcome for safe discharge were examined. Transfusion strategy was dichotomised and defined as "liberal" when transfusion was administered for haemoglobin (Hb) ≥80 g/L (or ≥90 g/L in patients with acute coronary syndrome) or major haemorrhage, and "restrictive" otherwise. Multivariable logistic regression models were used to assess the independent association between liberal RBC transfusion and outcomes. Results:Of 2528 consecutive patients enrolled from 143 hospitals in the original study, 666 (26.3%) received RBC transfusion (mean age 73.3 ± 16 years, 49% female, initial mean haemoglobin 90 ± 24 g/L, 2.3% had haemodynamic instability).The rebleeding rate in transfused patients was 42.3%. After adjusting for potential confounders, there was no difference between liberal and restrictive RBC transfusion strategies for the odds of rebleeding (OR 0.89, 95% CI 0.6-1.22), in-hospital mortality (OR 0.54, 95% CI 0.3-1.1) or of achieving the composite outcome (OR 0.72, 95% CI 0.5-1.1). Conclusion:Although these results could be due to residual confounding, they provide an important foundation for the design of randomised trials to evaluate transfusion strategies for LGIB.Omar Kherad and Sophie Restellini contributed equally to this work.

Efficacy and Safety of Early vs Elective Colonoscopy for Acute Lower Gastrointestinal Bleeding

“…We assessed the severity of bleeding by using hemoglobin level data and vital signs, including systolic blood pressure and pulse rate, at the initial visit; these are the most frequent factors appearing in various severity scoring systems, 18 along with blood transfusion indications for lower gastrointestinal bleeding. 19 We categorized severe as hemoglobin <8 g/dL, systolic blood pressure <90 mm Hg, or pulse rate !100 beats/min; moderate was defined as hemoglobin !8 g/dL. For the per-protocol analysis population, the early colonoscopy group had colonoscopy performed within 24 hours of the initial visit, and the elective colonoscopy group had the procedure performed between 24 and 96 hours.…”

Editorial: blood transfusion for lower gastrointestinal bleeding—authors’ reply

“…We appreciate the comments from Dr Taha concerning our study . In contrast with upper gastrointestinal bleeding, there is indeed no evidence to inform the optimal approach to transfusion in patients with lower gastrointestinal bleeding (LGIB), which differs in its aetiology, clinical course and patient characteristics.…”

Editorial: blood transfusion for lower gastrointestinal bleeding

“…Evaluation of the risks of blood transfusion has been the subject of several studies in upper gastrointestinal bleeding (UGIB), but little is known about these in lower gastrointestinal bleeding (LGIB). This in turn highlights the relevance of the recent study in AP&T by Kherad et al The authors aimed to assess the association between red blood cell liberal vs restrictive transfusion strategies and outcomes in patients with LGIB. Transfusion strategy was ‘liberal’ when blood was administered for haemoglobin >80 g/L—or >90 g/L in patients with acute coronary syndrome or major haemorrhage—and ‘restrictive’ otherwise.…”

“…Kherad et al also provided some enlightenment but little comfort to clinicians or their patients with LGIB. To their credit, the authors’ conclusions highlight the likely role played by residual confounding factors.…”

“…To their credit, the authors’ conclusions highlight the likely role played by residual confounding factors. One key factor to be considered is that studies on restrictive vs liberal transfusion might simply be comparing giving a small or a bigger amount of blood, and this itself might be affected by subjective factors despite all efforts to the contrary . It would be interesting to compare the outcomes of blood transfusion vs resuscitation using non‐blood–related fluids or products.…”