Transfusion strategies for acute upper gastrointestinal bleeding

Càndid Villanueva, Alan Colomo, Alba Bosch, Mar Concepción, Virginia Hernandez-Gea, Carles Aracil, Isabel Graupera, María Poca, Cristina Alvarez-Urturi, Jordi Gordillo, Carlos Guarner-Argente, Miquel Santaló, Eduardo Muñiz, Carlos Guarner

Research output: Contribution to journalArticleResearchpeer-review

712 Citations (Scopus)

Abstract

Background: The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy. Methods: We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis. Results: A total of 225 patients assigned to the restrictive strategy (51%), as compared with 65 assigned to the liberal strategy (15%), did not receive transfusions (P<0.001). The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy. Conclusions: As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713). Copyright © 2013 Massachusetts Medical Society.
Original languageEnglish
Pages (from-to)11-21
JournalNew England Journal of Medicine
Volume368
Issue number1
DOIs
Publication statusPublished - 3 Jan 2013

Fingerprint Dive into the research topics of 'Transfusion strategies for acute upper gastrointestinal bleeding'. Together they form a unique fingerprint.

  • Cite this

    Villanueva, C., Colomo, A., Bosch, A., Concepción, M., Hernandez-Gea, V., Aracil, C., Graupera, I., Poca, M., Alvarez-Urturi, C., Gordillo, J., Guarner-Argente, C., Santaló, M., Muñiz, E., & Guarner, C. (2013). Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine, 368(1), 11-21. https://doi.org/10.1056/NEJMoa1211801