Transfusion Strategy In Patients Research Articles

Risks of Restrictive Versus Liberal Red Blood Cell Transfusion Strategies in Patients With Cardiovascular Disease: An Updated Meta-Analysis.

Risks of Restrictive Versus Liberal Red Blood Cell Transfusion Strategies in Patients With Cardiovascular Disease: An Updated Meta-Analysis.

Efficacy and safety of restrictive versus liberal blood transfusion strategies in acute myocardial infarction and anemia: a systematic review and meta-analysis of randomized controlled trials.

Blood transfusion strategies in patients with acute myocardial infarction (AMI) and anemia are yet to be conclusively identified. Thus, we aim to assess the efficacy and safety of restrictive versus liberal blood transfusion strategies for AMI and anemia. A systematic review and meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, web of science, SCOPUS, EMBASE, and Cochrane Central Register of Controlled Trials were performed through November 2023. We used RevMan V. 5.4 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI). (PROSPERO): ID: CRD42023490692. We included four RCTs with 4.325 patients. There was no significant difference between both groups regarding MACE whether at 30 days (RR: 0.93 with 95% CI [0.57-1.51], P = 0.76) or ≥ six months (RR: 1.17 with 95% CI [0.95-1.45], P = 0.14), all-cause mortality at 30 days (RR: 1.16 with 95% CI [0.95-1.40], P = 0.14) or ≥ six months (RR: 1.16 with 95% CI [0.88-1.53], P = 0.28). However, the liberal strategy was significantly associated with increased hemoglobin level change (MD: -1.44 with 95% CI [-1.68 to -1.20], P < 0.00001). However, the restrictive strategy was significantly associated with a lower incidence of acute lung injury (RR: 0.11 with 95% CI [0.02-0.60], P = 0.01). There was no significant difference between the restrictive blood transfusion strategy and the liberal blood transfusion strategy regarding the clinical outcomes. However, restrictive blood transfusion strategy was significantly associated with a lower incidence of acute lung injury than liberal blood transfusion strategy.

Restrictive vs Liberal Blood Transfusions for Patients With Acute Myocardial Infarction and Anemia by Heart Failure Status: An RCT Subgroup Analysis

BackgroundRed blood cell transfusion can cause fluid overload. We evaluated the interaction between heart failure (HF) at baseline and transfusion strategy on outcomes in acute myocardial infarction (AMI). MethodsWe used data from the randomized REALITY trial. HF was defined as history of HF or Killip class > 1 at randomization. Primary outcome was major adverse cardiovascular events (MACE): composite of all-cause death, nonrecurrent AMI, stroke, or emergency revascularization prompted by ischemia at 30 days. ResultsAmong 658 randomized patients, 311 (47.3%) had HF. Patients with HF had higher rates of MACE at 30 days and 1 year and higher rates of nonfatal new-onset HF. There was no interaction between HF and effect of randomized assignment on the primary outcome or nonfatal new-onset HF. A liberal transfusion strategy was associated with increased all-cause death at 30 days and at 1 year in patients with HF (Pinteraction = 0.009 and P = 0.049, respectively). The main numerical difference in cause of death between restrictive and liberal strategies was death by HF at 30 days (4 vs 11). ConclusionsHF is frequent in patients with AMI and anemia and is associated with higher risk of MACE (including all-cause death) and nonfatal new-onset HF. Although there was no interaction of HF with effect of transfusion strategy on MACE, a liberal transfusion strategy was associated with higher all-cause death that appears driven by a higher risk of early death caused by HF. Clinical Trial RegistrationNCT02648113.

Effect of a restrictive vs. liberal blood transfusion strategy among patients with acute myocardial infarction and anemia according to heart failure. A subgroup analysis of the REALITY trial

Abstract Background/Introduction The optimal Red Blood Cell (RBC) transfusion strategy in patients with acute myocardial infarction (MI) and anemia remains debated. In REALITY, the largest randomized trial to date in this population (n=666), a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of major adverse cardiovascular events (MACE; composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia) at 30 days, but did not achieve non-inferiority at 1 year. One of the main concerns with RBC transfusion is the risk of fluid overload and acute heart failure (HF). Therefore, the balance of benefit and risk of transfusions strategies may differ between patients with and without heart failure. Purpose We aimed to evaluate the potential interaction between HF and RBC transfusion on outcomes in REALITY. Methods HF was defined as either a history of heart failure or Killip class &amp;gt; 1 at randomization (data available for 658 patients). All events until day 30, including HF, were adjudicated by a Critical Event Committee blinded to the transfusion arm and hemoglobin levels. The primary clinical outcome was MACE at 30 days. Secondary endpoints included MACE at one year, individual components of MACE and new onset of heart failure at 30 days and 1 year. Results Among 658 patients, 311 (47.3 %) had HF. HF patients had a higher rate of MACE and a higher rate of new HF than patients without HF at 30 day and at 1 year (Fig 1). There was no interaction between HF and the effect of randomized assignment on the primary outcome or on new HF. In contrast, a liberal strategy was associated with increased all-cause death at 30 days and at 1 year in patients with HF but not in pts without HF (interaction p = 0.0088 and p = 0.049 respectively, Fig 1). Conclusion(s) Heart failure is frequent in MI patients with anemia (nearly half of the patients) and is associated with higher risks of MACE and of HF. While no interaction was observed between HF and transfusion strategies on the primary outcome of MACE, a liberal transfusion strategy was associated with higher all-cause mortality than a restrictive strategy both at 30-days and 1 year. The mechanism of this interaction deserves further investigation.

Preoperative Exchange Transfusion for Patients with SCD Systematic Review

Introduction: Sickle cell disease (SCD) is the most common genetic disease world wide with the highest prevalence in Africa, Middle east, and east Asia. Surgeries in patients with SCD are associated with a higher rate of perioperative complications, however, there is no solid recommendations in the guidelines to advice perioperative transfusion strategies in patients with SCD. This review investigated the current available evidence in the literature to provide a clearer guidance. Methods: PubMed and Embase electronic search identified 655 articles related to randomized controlled trials and observational studies about the safety of perioperative transfusion in SCD. After removing duplicates and non-relevant articles 39 articles were evaluated in full text for eligibility, of which 24 studies were found eligible for inclusion in qualitative analysis and 16 studies with 3486 participants eligible for inclusion in the quantitative analysis. Assessment of quality and risk of Bias was done using the Cochrane tool for RCTs and ROBBINS-I tool for observational non randomized studies. The safety outcomes of perioperative transfusion, including acute chest syndrome (ACS), painful crisis, neurological complications, fever, minor or major bleeding, thrombosis, intensive care unit (ICU) admission, and all-cause mortality were assessed in comparison to SCD patients undergoing surgeries with conservative transfusion strategy. The risk ratio (RR) with 95% confidence intervals (CI) were calculated for the desired outcomes, the data was combined in forest plots and meta-analysis using the random-effects model. Results: Of the 24 studies included, 13 studies had the control arm as no transfusion in comparison to perioperative transfusion, while the remaining studies had conservative strategy guided by hemoglobin level as a control. Sixteen studies reported ACS among SCD patients who received perioperative transfusion (n=1890) versus conservative transfusion strategy (n=1596) (RR= 0.91, 95% CI 0.58-1.41, I2= 58%) (Figure 1-A). Fifteen studies reported painful crisis with perioperative transfusion (n=1856) versus conservative transfusion strategy (n=1532) (RR= 0.94, 95% CI 0.53-1.68, I2= 63%) (Figure 1-B). Neurological complications associated with the perioperative transfusion in SCD (n=1590) compared to conservative transfusion strategy (n=1250) were reported in nine studies (RR= 1.38, 95% CI 0.54-3.57, I2= 0%). Seven studies reported fever as a post-operative complication following perioperative transfusion in SCD (n= 1243) versus conservative transfusion (n= 922) (RR= 1.36, 95% CI 0.94-1.97, I2= 51%). Six studies reported bleeding following perioperative transfusion in SCD (n= 847) versus conservative strategy (n= 477) (RR= 4.32, 95% CI 1.75-10.68, P=0.002, I2= 0%) (Figure 1-C). Three studies reported thrombotic events following the perioperative transfusion in SCD (n= 885) versus conservative transfusion (n= 404) (RR= 0.59, 95% CI 0.06-5.68, I2= 0%). ICU admissions were reported in three studies with perioperative transfusion (n= 53) versus conservative transfusion (n= 147) (RR= 4.99, 95% CI 0.98-25.48, I2= 0%). Mortality was reported in six studies with perioperative transfusion (n= 1320) versus conservative transfusion (n= 977) (RR= 0.67, 95% CI 0.05-8.75, I2= 71%). Conclusion: According to this systematic review and meta-analysis Perioperative transfusion in SCD resulted in significantly higher rate of bleeding compare to conservative strategies while the rates of acute chest syndrome, painful crisis, fever, neurological complications, thrombosis, ICU admission, and mortality remained similar between the two strategies.

Transfusion trigger after operations in high cardiac risk patients (TOP) trial protocol. Protocol for a multicenter randomized controlled transfusion strategy trial

BackgroundThere is substantial uncertainty regarding the effects of restrictive postoperative transfusion among patients who have underlying cardiovascular disease. The TOP Trial's objective is to compare adverse outcomes between liberal and restrictive transfusion strategies in patients undergoing vascular and general surgery operations, and with a high risk of postoperative cardiac events. MethodsA two-arm, single-blinded, randomized controlled superiority trial will be used across 15 Veterans Affairs hospitals with expected enrollment of 1520 participants. Postoperative transfusions in the liberal arm commence when Hb is <10 g/ dL and continue until Hb is greater than or equal to 10 g/dL. In the restrictive arm, transfusions begin when Hb is <7 g/dL and continue until Hb is greater than or equal to 7 g/dL. Study duration is estimated to be 5 years including a 3-month start-up period and 4 years of recruitment. Each randomized participant will be followed for 90 days after randomization with a mortality assessment at 1 year. ResultsThe primary outcome is a composite endpoint of all-cause mortality, myocardial infarction (MI), coronary revascularization, acute renal failure, or stroke occurring up to 90-days after randomization. Events rates will be compared between restrictive and liberal transfusion groups. ConclusionsThe TOP Trial is uniquely positioned to provide high quality evidence comparing transfusion strategies among patients with high cardiac risk. Results will clarify the effect of postoperative transfusion strategies on adverse outcomes and inform postoperative management algorithms.TRIAL REGISTRATION: http://clinicaltrials.gov identifier: NCT03229941

Restrictive versus liberal transfusion for anemic patients with acute myocardial infarction: Systematic review and meta-analysis

• Meta-analysis of RCTs comparing transfusion thresholds for patients with acute MI and anemia failed to exclude either appreciable harm or benefit. • The mechanism by which blood transfusions are thought to improve outcomes in patients with MI and anemia requires further investigation. • Additional research utilizing published results from larger randomized controlled trials is needed to understand the relative safety of liberal to restrictive blood transfusion strategies and overcome the quality limitations of current evidence. The optimal blood transfusion threshold for patients with acute myocardial infarction (MI) and anemia is unclear. This meta-analysis aimed to assess the safety of restrictive transfusion to liberal thresholds. We searched MEDLINE, EMBASE, Web of Science, and CENTRAL for randomized controlled trials comparing different transfusion strategies in patients with acute MI. Two independent reviewers screened the studies for inclusion, extracted data, evaluated methodological quality, and assessed the quality of evidence. Primary outcomes were all measured at 30-days post-randomization and included: All-cause mortality, heart failure, recurrent MI, and stroke. A random-effects model was used. Our searches yielded a total of 5980 unique results. Three studies were eligible and included in the analysis (n = 821 patients). In all studies, the restrictive and liberal thresholds were equivalent to 8g/dL and 10g/dL hemoglobin, respectively. There was no significant difference in all-cause mortality (RR = 0.63; 95% CI 0.15 to 2.66; P = 0.53; I 2 = 59%), heart failure (RR = 1.17; 95% CI 0.31 to 4.34; P = 0.82; I 2 = 70%), recurrence of MI (RR = 1.61; 95% CI 0.65 to 4.02; P = 0.30; I 2 = 0%), or stroke (RR = 1.41; 95% CI 0.27 to 7.43; P = 0.69; I 2 = 0%). Our meta-analysis found no significant difference in the primary outcomes between transfusion strategies for patients with acute MI and anemia. Results from trials with larger sample sizes is needed to clarify the dilemma between transfusion strategies in this population.

2021: Perioperative and critical care year in review for the cardiothoracic surgery team

For yet another year, our lives have been dominated by a pandemic. This year in review, we feature an expert panel opinion regarding extracorporeal support in the context of COVID-19, challenging previously held standards. We also feature survey results assessing the impact of the pandemic on cardiac surgical volume. Furthermore, we focus on a single center experience that evaluated the use of pulmonary artery catheters and the comparison of transfusion strategies in the Restrictive and Liberal Transfusion Strategies in Patients With Acute Myocardial Infarction (REALITY) trial. Additionally, we address the impact of acute kidney injury on cardiac surgery and highlight the controversy regarding the choice of fluid resuscitation. We close with an evaluation of dysphagia in cardiac surgery and the impact of prehabilitation to optimize surgical outcomes.

Restrictive versus Liberal Blood Transfusion Strategy in Patients With Acute Myocardial Infarction: A Meta-Analysis of Randomized Clinical Trials.

BackgroundA meta-analysis of observational studies comparing differences in outcomes between restrictive blood transfusion (RBT) and liberal blood transfusion (LBT) in patients with acute myocardial infarction (AMI) reported that LBT is associated with higher all-cause mortality. Few randomized clinical trials (RCTs) have compared RBT to LBT in patients with AMI and anemia, but no meta-analysis of RCTs was performed to date.AimTo assess the clinical effect of RBT compared to LBT in patients with AMI and anemia regarding was all-cause mortality, recurrent MI, revascularization, and heart failure exacerbation.MethodsThe electronic databases Ovid MEDLINE, EMBASE, Cochrane Central, Scopus, and Google Scholar, were systematically searched to identify eligible studies published before June 19th, 2021. RCTs that assessed the effect of RBT compared to LBT were included. The primary endpoint was all-cause mortality. Secondary endpoints included recurrent MI, revascularization, and heart failure exacerbation.ResultsThree RCTs with 821 patients were included (421 received RBT, and 400 received LBT). The mean age was 75.9 ± 6.1 years, and 56% were male. Our meta-analysis showed that RBT was not associated with reduced all-cause mortality (RR = 1.61; 95% CI = 0.38–6.96, p = 0.52), recurrent MI (RR = 0.98; 95% CI = 0.48–1.96, p = 0.94), revascularization (RR = 1.18; 95% CI = 0.26–5.44, p = 0.83) and heart failure exacerbation (RR = 0.86; 95% CI = 0.23–3.22, p = 0.82) when compared to LBT.ConclusionRBT was not associated with reduced all-cause mortality, recurrence of MI, need for revascularization, or heart failure exacerbation in patients with AMI and anemia compared to LBT. A larger RCT is required to confirm the above findings.

Transfusion strategies in patients with acute coronary syndrome and anemia: a meta-analysis

BackgroundAnemia is a known risk factor for ischemic heart disease and serves as an independent predictor of major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS). This meta-analysis pools data from randomized controlled trials (RCTs) to better define hemoglobin (Hb) thresholds for transfusion in this setting.ResultsMEDLINE, EMBASE, and Cochrane databases were searched using the terms “Acute Coronary Syndrome” AND “Blood Transfusion” including their synonyms. A total of three randomized controlled trials were included. Restrictive transfusion strategy (RTS) was defined as transfusing for Hb ≤ 8 g/dl with a post-transfusion goal of 8 to 10 g/dl. Liberal transfusion strategy (LTS) was defined as Hb ≤ 10 g/dl and post-transfusion goal of at least 11 g/dl. The primary end point was 30-day mortality. Secondary outcomes included recurrent ACS events, new or worsening CHF within 30 days, and major adverse cardiac events (MACE). The primary analytic method used was random effects model. Out of 821 patients, 400 were randomized to LTS, and 421 to RTS. Mean age was 70.3 years in RTS versus 76.4 in LTS. There was no statistically significant difference for 30-day mortality in LTS compared to RTS [odds ratio (OR) 1.69; 95% CI 0.35 to 8.05]. Similarly, there was no difference in MACE (OR 0.74; 95% CI 0.21 to 2.63), CHF (OR 0.82; 95% CI 0.18 to 3.76), or the incidence of recurrent ACS (OR 1.21; 95% CI 0.49 to 2.95).ConclusionsIn the setting of ACS, there is no difference between LTS and RTS for the outcomes of mortality, MACE, recurrent ACS, or CHF at 30 days. Further evidence in the form of high-quality RCTs are needed to compare RTS and LTS.

Restrictive vs. Liberal Red Blood Cell Transfusion Strategy in Patients With Acute Myocardial Infarction and Anemia: A Systematic Review and Meta-Analysis

Objective: Anemia is frequent in patients with acute myocardial infarction (AMI), and the optimal red blood cell transfusion strategy for AMI patients with anemia is still controversial. We aimed to compare the efficacy of restrictive and liberal red cell transfusion strategies in AMI patients with anemia.Methods: We systematically searched PubMed, EMBASE, Web of Science, Cochrane Library, and Clinicaltrials.gov, from their inception until March 2021. Studies designed to compare the efficacy between restrictive and liberal red blood cell transfusion strategies in patients with AMI were included. The primary outcome was all-cause mortality, including overall mortality, in-hospital or follow-up mortality. Risk ratios (RR) with 95% confidence intervals (CI) were presented and pooled by random-effects models.Results: The search yielded a total of 6,630 participants in six studies. A total of 2,008 patients received restrictive red blood cell transfusion while 4,622 patients were given liberal red blood cell transfusion. No difference was found in overall mortality and follow-up mortality between restrictive and liberal transfusion groups (RR = 1.07, 95% CI = 0.82–1.40, P = 0.62; RR = 0.89, 95% CI = 0.56–1.42, P = 0.62). However, restrictive transfusion tended to have a higher risk of in-hospital mortality compared with liberal transfusion (RR = 1.22, 95% CI = 1.00–1.50, P = 0.05). No secondary outcomes, including follow-up reinfarction, stroke, and acute heart failure, differed significantly between the two groups. In addition, subgroup analysis showed no differences in overall mortality between the two groups based on sample size and design.Conclusion: Restrictive and liberal red blood cell transfusion have a similar effect on overall mortality and follow-up mortality in AMI patients with anemia. However, restrictive transfusion tended to have a higher risk of in-hospital mortality compared with liberal transfusion. The findings suggest that transfusion strategy should be further evaluated in future studies.

Optimal blood management as priority route in cardiac surgery

Introduction. Generating manifold publications over decades, research continues assessing the burden of perioperative bleeding, preoperative anaemia and red blood component (RBC) transfusion in cardiac surgical patients. The past decade is witnessing a trend towards limited RBC transfusion. Nevertheless, the risk and justifi cation of a restrictive or liberal transfusion strategy in cardiac surgery remain a matter of debate.Aim — a description of evidence estimating the impact of bleeding, preoperative anaemia, red-cell transfusion and restrictive vs. liberal strategies on the risk of mortality and other adverse events in adults with cardiac surgery.Methods. Relevant evidence was mined in PubMed for the period 2012–2019. The query phrases were: cardiac surgery [кардиохирургия], bleeding [кровотечение], preoperative anaemia [предоперационная анемия], red-cell transfusion [переливание эритроцитов], restrictive and liberal transfusion strategy [рестриктивная и либеральная трансфузионная стратегия]. The review includes 18 studies describing outcomes related to bleeding, preoperative anaemia of varying severity and variant-volume RBC transfusion in patients with cardiac surgery. Nine studies comparatively assessed the cardiac surgical clinical outcomes under restrictive and liberal transfusion strategies. A total of 24 full texts have been analysed, one randomised clinical trial (RCT) summary, one retrospective trial summary and one meta-analysis review. Additional studies of concern to discussion have also been considered.Results. One prospective and four retrospective studies evaluated the effect of perioperative bleeding on the risk of subsequent adverse events in patients with cardiac surgery. Three prospective, fi ve retrospective studies and one RCT revealed the association of red-cell transfusion with adverse outcomes. Five retrospective studies exposed a link between preoperative anaemia and reason for RBC transfusions. Six retrospective studies found an independent association between the risk of postoperative complications and mortality in patients having cardiac surgery and preoperative anaemia. Eight RCTs and one meta-analysis of seven RCTs presented comparative data on clinical outcomes of restrictive and liberal transfusion strategies in patients after heart surgery.Conclusion. Preoperative anaemia, haemorrhage and donated component transfusion independently contribute to the risk of serious postoperative complications and death unifying in the “deadly triad” of cardiac surgery. RBC transfusions are integrally indicative of the aid quality in cardiac surgery reflecting the success of blood management system in the hospital. Leveraging a good patient blood management practice at all treatment steps to involve a multispecialty blood-team approach can significantly improve patient outcomes at a higher cost efficiency.

Restrictive vs liberal blood transfusion strategy in patients with symptomatic coronary artery disease: meta-analysis from randomized controlled trials

Abstract Background Anemia is common in patients with symptomatic coronary artery disease. Observational studies investigated blood transfusion threshold in symptomatic coronary artery disease but results were conflicting. Meta-analyses evaluating transfusion threshold utilized data mainly from observational trials but no meta-analysis, to our knowledge, used data solely from randomized clinical trials. Objective The goal of our study is to evaluate efficacy and safety outcomes in anemic patients presenting with symptomatic coronary artery disease using pooled data from randomized clinical trials. Methods We queried Medline, Embase and Cochrane data bases for randomized clinical trials comparing restrictive blood transfusion (defined as transfusion when hemoglobin is less than 8 gm/dl) vs liberal blood transfusion (transfusion when hemoglobin is less than 10 gm/dl) in patients presenting with symptomatic artery disease or acute coronary syndrome. We identified 3 randomized controlled trials; MINT, CRIT and REALITY trials. Data were pooled from 3 trials. Efficacy outcomes evaluated were all-cause mortality and New or recurrent myocardial infarction. Safety outcomes were congestive heart failure at 30-day follow up. Results A total of 820 patients were included in our meta-analysis; 420 patients in restrictive blood transfusion protocol and 400 in liberal blood transfusion protocol There was no difference between two groups at 30-day follow up in all identified outcomes (all-cause mortality, new or recurrent myocardial infarction, and Congestive heart failure). 55 patients died (22/420 in restrictive group and 33/400 in liberal group). Risk ratio of all-cause mortality in restrictive group was 0.63 [95% CI (0.38–1.07), P=0.09, I2=30%]. 15/420 in restrictive group and 16/400 in liberal group had new or recurrent myocardial infarction. Risk ratio of myocardial infarction in restrictive group was 0.91 [95% CI (0.46–1.80), P=0.78, I2=0%]. 20/420 patients in restrictive group and 24/400 in liberal group had congestive heart failure with risk ratio of 0.80 [95% CI (0.19–3.37), P=0.30, I2=76%] in restrictive group. Conclusion Our meta-analysis showed similar outcomes between restrictive and liberal transfusion policies in patients presenting with symptomatic coronary artery disease of acute myocardial infarction. Our findings are consistent with available data about restricting transfusion in general population. Restricting blood transfusion might be cost-effective. Further studies are warranted to evaluate long term safety and efficacy of such approach. Funding Acknowledgement Type of funding sources: None.

Pre-Transfusion Testing and Transfusion Strategy in Patients with Multiple Myeloma after Daratumumab Treatment

To investigate the procedure of pre-transfusion testing and transfusion strategy of patients with multiple myeloma (MM) treated by daratumumab (DarA). The blood samples of MM patients before and after DarA treatment from the Fifth Affiliated Hospital of Sun Yat-sen University were collected, and the ABO/Rh blood group antigen identification and DAT test results were compared. The results of antibody screening and cross matching of the patients before and after inactivation of red blood cells with 0.2 mol/L dithiothreitol (DTT) were compared and analyzed. ABO/Rh blood group antigen typing showed no affecting in patients after treated by DarA; the result of DAT test showed negative. Irregular antibody screening showed that all the three cells(Ⅰ, Ⅱ and Ⅲ) were positive(1+~2+) and the self-control was negative. By microcolumn agglutination method, the main side of the multi-bag of blood showed no matched, while the secondary side showed all identical. After treated by DTT solution, the cross matching results in reagent red blood cells and the red blood cells of blood donors were both consistent, and the irregular antibody screening was negative. The K(+)O type erythrocytes used in parallel control were transformed into K(-)O type erythrocytes after DTT treatment. However, there was no significant changes in E(+) O type erythrocytes before and after DTT treatment. There was no condensation on the primary and secondary side of the condensed amine method. The primary and secondary sides of blood matching by saline method showed negative. After treated by DarA, cross matching results from microcolumn agglutination method can be interfered by the residual drug antibody in MM patients, while the interference was eliminated in the presence of 0.2 mol/L DTT solution. However, no disturbance was observed when using condensed amine method or saline method. Therefore, corresponding transfusion procedures should be selected according to the emergency degree of blood transfusion to ensure the safety and timeliness of blood transfusion.

Transfusion Strategies in Patients with Mitral Valve Replacement

The aim. To carry out research of liberal, restrictive and blood-saving transfusion strategies in patients with mitral valve replacement (MVR) in the conditions of artificial blood circulation during operation, in intensive care unit, and in the postoperative period.&#x0D; Material and methods. Retrograde examinations were performed in 70 patients who underwent surgery for ac-quired mitral valve disease. Our research consisted of three stages: stage 1 involved the study of the volume of transfu-sions of donor blood components during MVR, stage 2 involved the study of the volume of transfusion of donor blood components in the emergency room, stage 3 involved the study of the volume of transfusions of donor blood components in the intensive care unit. All the patients were divided into 3 groups. Group A included 14 patients in whom (arbitrary) liberal transfusion strategy (LTS) with transfusion of donor blood components was applied during the operation. Group B included 19 patients in whom (economical) restrictive transfusion strategy (RTS) during surgery with transfusion of donor blood components was applied. Group C included 37 patients in whom the patient’s autologous blood-saving tech-nology (BST) was applied during the operation.&#x0D; Results and discussion. At stage 1 of the study, the volume of packed RBCs per 1 transfusion in group A exceeded the volume of packed RBCs per 1 transfusion in group B by 68.0%. The volume of transfusions of native fresh-frozen plasma (FFP) in group A exceeded that in group B by 73.5%. The volume of platelet transfusions (PT) in group A at stage 1 was 75.0%. At stage 2 of the study, the total volume of PT in patients of group A was still 3.0 times higher and FFP was 2.7 times higher than that in group B. At this stage of the study, there was also a 2.6-fold decrease in the volume of PT per 1 transfusion in group B compared with group A. In total, during 3 stages of the study, the volume of PT use in group A was 5.7 times higher, and in group B it was 3.9 times higher than that in group C. The volume of FFP use in group A was 4.4 times higher, and in group B it was 3.8 times higher than that in group C.&#x0D; Conclusions. The use of LTS in group A and RTS in group B resulted in 5.2-fold and 3.8-fold increase in the total volume of transfused donor blood components, repsectively, compared to group C.

Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia

The optimal transfusion strategy in patients with acute myocardial infarction and anemia is unclear. To determine whether a restrictive transfusion strategy would be clinically noninferior to a liberal strategy. Open-label, noninferiority, randomized trial conducted in 35 hospitals in France and Spain including 668 patients with myocardial infarction and hemoglobin level between 7 and 10 g/dL. Enrollment could be considered at any time during the index admission for myocardial infarction. The first participant was enrolled in March 2016 and the last was enrolled in September 2019. The final 30-day follow-up was accrued in November 2019. Patients were randomly assigned to undergo a restrictive (transfusion triggered by hemoglobin ≤8; n = 342) or a liberal (transfusion triggered by hemoglobin ≤10 g/dL; n = 324) transfusion strategy. The primary clinical outcome was major adverse cardiovascular events (MACE; composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia) at 30 days. Noninferiority required that the upper bound of the 1-sided 97.5% CI for the relative risk of the primary outcome be less than 1.25. The secondary outcomes included the individual components of the primary outcome. Among 668 patients who were randomized, 666 patients (median [interquartile range] age, 77 [69-84] years; 281 [42.2%] women) completed the 30-day follow-up, including 342 in the restrictive transfusion group (122 [35.7%] received transfusion; 342 total units of packed red blood cells transfused) and 324 in the liberal transfusion group (323 [99.7%] received transfusion; 758 total units transfused). At 30 days, MACE occurred in 36 patients (11.0% [95% CI, 7.5%-14.6%]) in the restrictive group and in 45 patients (14.0% [95% CI, 10.0%-17.9%]) in the liberal group (difference, -3.0% [95% CI, -8.4% to 2.4%]). The relative risk of the primary outcome was 0.79 (1-sided 97.5% CI, 0.00-1.19), meeting the prespecified noninferiority criterion. In the restrictive vs liberal group, all-cause death occurred in 5.6% vs 7.7% of patients, recurrent myocardial infarction occurred in 2.1% vs 3.1%, emergency revascularization prompted by ischemia occurred in 1.5% vs 1.9%, and nonfatal ischemic stroke occurred in 0.6% of patients in both groups. Among patients with acute myocardial infarction and anemia, a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of MACE after 30 days. However, the CI included what may be a clinically important harm. ClinicalTrials.gov Identifier: NCT02648113.

Restrictive vs liberal red blood cell transfusion strategies in patients with acute myocardial infarction and anemia: Rationale and design of the REALITY trial.

BackgroundAnemia is common in patients with acute myocardial infarction (AMI), and is an independent predictor of mortality. The optimal transfusion strategy in these patients is unclear.HypothesisWe hypothesized that a “restrictive” transfusion strategy (triggered by hemoglobin ≤8 g/dL) is clinically noninferior to a “liberal” transfusion strategy (triggered by hemoglobin ≤10 g/dL), but is less costly.MethodsREALITY is an international, randomized, multicenter, open‐label trial comparing a restrictive vs a liberal transfusion strategy in patients with AMI and anemia. The primary outcome is the incremental cost‐effectiveness ratio (ICER) at 30 days, using the primary composite clinical outcome of major adverse cardiovascular events (MACE; comprising all‐cause death, nonfatal stroke, nonfatal recurrent myocardial infarction, or emergency revascularization prompted by ischemia) as the effectiveness criterion. Secondary outcomes include the ICER at 1 year, and MACE (and its components) at 30 days and at 1 year.ResultsThe trial aimed to enroll 630 patients. Based on estimated event rates of 11% in the restrictive group and 15% in the liberal group, this number will provide 80% power to demonstrate clinical noninferiority of the restrictive group, with a noninferiority margin corresponding to a relative risk equal to 1.25. The sample size will also provide 80% power to show the cost‐effectiveness of the restrictive strategy at a threshold of €50 000 per quality‐adjusted life year.ConclusionsREALITY will provide important guidance on the management of patients with AMI and anemia.

A restrictive versus liberal transfusion strategy to prevent myocardial injury in patients undergoing surgery for fractured neck of femur: a feasibility randomised trial (RESULT-NOF)

BackgroundThe optimum transfusion strategy in patients with fractured neck of femur is uncertain, particularly if there is coexisting cardiovascular disease. MethodsWe conducted a prospective, single-centre, randomised feasibility trial of two transfusion strategies. We randomly assigned patients undergoing surgery for fractured neck of femur to a restrictive (haemoglobin, 70–90 g L−1) or liberal (haemoglobin, 90–110 g L−1) transfusion strategy throughout their hospitalisation. Feasibility outcomes included: enrolment rate, protocol compliance, difference in haemoglobin, and blood exposure. The primary clinical outcome was myocardial injury using troponin estimations. Secondary outcomes included major adverse cardiac events, postoperative complications, duration of hospitalisation, mortality, and quality of life. ResultsWe enrolled 200 (22%) of 907 eligible patients, and 62 (31%) showed decreased haemoglobin (to 90 g L−1 or less) and were thus exposed to the intervention. The overall protocol compliance was 81% in the liberal group and 64% in the restrictive group. Haemoglobin concentrations were similar preoperatively and at postoperative day 1 but lower in the restrictive group on day 2 (mean difference [MD], 7.0 g L−1; 95% confidence interval [CI], 1.6–12.4). Lowest haemoglobin within 30 days/before discharge was lower in the restrictive group (MD, 5.3 g L−1; 95% CI, 1.7–9.0). Overall, 58% of patients in the restrictive group received no transfusion compared with 4% in the liberal group (difference in proportion, 54.5%; 95% CI, 36.8–72.2). The proportion with the primary clinical outcome was 14/26 (54%, liberal) vs 24/34 (71%, restrictive), and the difference in proportion was –16.7% (95% CI, –41.3 to 7.8; P=0.18). ConclusionA clinical trial of two transfusion strategies in hip fracture with a clinically relevant cardiac outcome is feasible. Clinical trial registrationNCT03407573.

Restrictive versus liberal transfusion strategy in upper gastrointestinal bleeding: A randomized controlled trial.

Background:The study aimed at comparing restrictive and liberal transfusion strategy in reducing mortality in patients with upper gastrointestinal bleeding (UGIB).Methods:This was a single-center, prospective, open-label, non-inferiority, randomized controlled trial conducted over two years. Patients presenting with UGIB were randomized into restrictive (hemoglobin (Hb) <7 g/dl) or liberal (Hb <8 g/dl) transfusion strategy groups. Transfusion was given till patients achieved target Hb of 9 g/dl in restrictive and 10 g/dl in the liberal arms. Patients with exsanguinating bleeding, transfusion within 90 days, recent history of trauma or surgery were excluded. Primary outcome was mortality rate and the secondary outcomes were morbidity, re-bleeding episodes and the need for intervention.Results:A total of 224 patients were randomized to 112 patients in each group. Demographic characteristics were comparable. 45-day mortality was similar between the two groups (restrictive vs. liberal; 10/112 vs. 12/112; P = 0.65). The number of in-hospital bleeding episodes (12 vs. 9; P = 0.25), incidence of re-bleeding during the 45-day follow-up (13 vs. 14; P = 0.84), need for endoscopic banding for varices (37/112 vs. 39/112, P = 0.99), mean hospital stay (days) (3.21 ± 2.78 vs. 2.73 ± 1.29; P = 0.10) were similar between the two groups.Conclusion:Restrictive transfusion strategy is non-inferior to liberal transfusion strategy in patients with UGIB.

Review of Therapeutic Erythrocytapheresis in Patients with Thalassemia Major

Introduction Therapeutic erythrocytapheresis, or red cell exchange (RCE) is a non-invasive procedure in which a patient's erythrocytes are removed from the bloodstream while being replaced with erythrocytes from blood donors. RCE is commonly used as a transfusion technique in patients with sickle cell disease (SCD) to help treat and prevent complications associated with sickling of erythrocytes and iron overload. In the rare blood disorders (RBD) clinic at the University of Alberta in Edmonton, Canada, RCE has been utilized as a therapeutic adjunct to traditional chelation therapies for patients with thalassemia major with uncontrolled iron overload. The aim of this study is to describe and review the rate of observed complications or benefits associated with RCE in patients with thalassemia major. Methods Patients with a documented diagnosis of thalassemia major who were enrolled in the RCE program via the RBD clinic were identified. Charts were retrospectively reviewed from time of initiation of RCE to the time of most recent RCE or clinic follow up. Complications were documented and analyzed, then compared to standard rates of complications of iron overload in patients with thalassemia major. Results Seven (7) patients with were identified for analysis. The average age of patients enrolled was 30 years. One hundred percent (100%) of patients had confirmed diagnosis of thalassemia major by hemoglobin electrophoresis. 85.7% of patients were of male sex. Six (85.7%) patients were on chelation therapy (3 patients on Jadenu plus Ferriprox; 3 patients on Jadenu alone). On average RCE was performed every 3.85 weeks. Of the patients analyzed during RCE, 85.7% had hepatic iron overload and 42.9% had cardiac dysfunction. 71.4% had evidence of extramedullary hematopoiesis. Two patients had syncopal events while on RCE. Two patients developed red cell antibodies during RCE. Improvements in iron overload correlated with initiation of dual chelation therapy in the three patients who were on maximal dual chelation. Conclusions Although RCE is a useful transfusion strategy in patients with SCD with less iron loading than simple transfusion, it does not appear to have the same benefits in patients with thalassemia major. Improvements in myocardial and hepatic T2* scores correlated with being on dual chelation therapy rather than with the frequency or duration of RCE. There was evidence of significant extramedullary hematopoiesis in 5 of the 7 patients on RCE possibly due to poor hemoglobin increment. Given the observed increase in extramedullary hematopoiesis, syncope, and antibody formation associated with RCE, and lack of benefit in reducing iron overload, we do not recommend its use as a treatment in patients with thalassemia major. Disclosures No relevant conflicts of interest to declare.