Outcomes among patients with acute upper gastrointestinal bleeding can be improved by employing a restrictive transfusion strategy that raises the threshold for the transfusion of red cells, the results of a Spanish study indicate.
The team, led by Càndid Villanueva, from Hospital de la Santa Creu i Sant Pau in Barcelona, says: "The risk of further bleeding, the need for rescue therapy, and the rate of complications were all significantly reduced, and the rate of survival was increased, with the restrictive transfusion strategy."
For the study, 921 patients with severe acute upper gastrointestinal bleeding were randomly assigned to undergo a restrictive strategy, with a transfusion performed when the hemoglobin (Hb) level fell below 7 g/dL, or a liberal strategy, with transfusion given when the Hb level fell below 9 g/dL. Bleeding was due to peptic ulcer in 49% of patients and to esophageal varices in a further 21%.
Significantly fewer patients in the restrictive strategy group received a transfusion than those in the liberal strategy group, at 14% versus 51%. Furthermore, restrictive strategy patients received significantly fewer transfusion units than liberal strategy patients, at a mean of 1.5 versus 3.7 units per patient.
Restrictive strategy patients had significantly lower mortality at 45 days than liberal strategy patients, at 5% versus 9%, which was unaffected by adjustment for baseline mortality risk factors. This yielded a mortality hazard ratio (HR) of 0.55. Unsuccessfully controlled bleeding was the cause of death in 0.7% of restrictive strategy patients and 3.1% of liberal strategy patients.
The team also reports in TheNew England Journal of Medicine that the rate of further bleeding was significantly lower in the restrictive strategy than the liberal strategy group, at 10% versus 16%. This yielded a HR for further bleeding of 0.68. Complications occurred in significantly fewer restrictive strategy patients than in liberal strategy patients, at 40% versus 48%.
Survival was slightly more likely with the restrictive strategy than in the liberal strategy group among patients with a peptic ulcer, at a HR of 0.70, and significantly more likely in patients with cirrhosis and Child-Pugh class A or B disease, at a HR of 0.30, but not in those with cirrhosis and Child-Pugh class C disease.
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