Amit X Garg1, Neal Badner2, Sean M Bagshaw3, Meaghan S Cuerden4, Dean A Fergusson5, Alexander J Gregory6, Judith Hall7, Gregory M T Hare7, Boris Khanykin8, Shay McGuinness9, Chirag R Parikh10, Pavel S Roshanov11, Nadine Shehata12, Jessica M Sontrop4, Summer Syed11, George I Tagarakis13, Kevin E Thorpe7, Subodh Verma7, Ron Wald7, Richard P Whitlock11, C David Mazer7. 1. Division of Nephrology, Department of Medicine, London Health Sciences Centre and Western University, London, Ontario, Canada; amit.garg@lhsc.on.ca. 2. Department of Anesthesia & Clinical Pharmacology, University of British Columbia, Kelowna, British Columbia, Canada. 3. Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada. 4. Division of Nephrology, Department of Medicine, London Health Sciences Centre and Western University, London, Ontario, Canada. 5. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. 6. Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada. 7. Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. 8. Cardiothoracic Anesthesiology Department, Copenhagen University Hospital, Copenhagen, Denmark. 9. Cardiothoracic and Vascular Intensive Care and High Dependency Unit, Auckland City Hospital, Auckland, New Zealand. 10. Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland. 11. Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada. 12. Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; and. 13. Department of Cardiothoracic Surgery, Aristotle University Hospital of Thessaloniki, Thessaloniki, Greece.
Abstract
BACKGROUND: Safely reducing red blood cell transfusions can prevent transfusion-related adverse effects, conserve the blood supply, and reduce health care costs. Both anemia and red blood cell transfusion are independently associated with AKI, but observational data are insufficient to determine whether a restrictive approach to transfusion can be used without increasing AKI risk. METHODS: In a prespecified kidney substudy of a randomized noninferiority trial, we compared a restrictive threshold for red blood cell transfusion (transfuse if hemoglobin<7.5 g/dl, intraoperatively and postoperatively) with a liberal threshold (transfuse if hemoglobin<9.5 g/dl in the operating room or intensive care unit, or if hemoglobin<8.5 g/dl on the nonintensive care ward). We studied 4531 patients undergoing cardiac surgery with cardiopulmonary bypass who had a moderate-to-high risk of perioperative death. The substudy's primary outcome was AKI, defined as a postoperative increase in serum creatinine of ≥0.3 mg/dl within 48 hours of surgery, or ≥50% within 7 days of surgery. RESULTS: Patients in the restrictive-threshold group received significantly fewer transfusions than patients in the liberal-threshold group (1.8 versus 2.9 on average, or 38% fewer transfusions in the restricted-threshold group compared with the liberal-threshold group; P<0.001). AKI occurred in 27.7% of patients in the restrictive-threshold group (624 of 2251) and in 27.9% of patients in the liberal-threshold group (636 of 2280). Similarly, among patients with preoperative CKD, AKI occurred in 33.6% of patients in the restrictive-threshold group (258 of 767) and in 32.5% of patients in the liberal-threshold group (252 of 775). CONCLUSIONS: Among patients undergoing cardiac surgery, a restrictive transfusion approach resulted in fewer red blood cell transfusions without increasing the risk of AKI.
RCT Entities:
BACKGROUND: Safely reducing red blood cell transfusions can prevent transfusion-related adverse effects, conserve the blood supply, and reduce health care costs. Both anemia and red blood cell transfusion are independently associated with AKI, but observational data are insufficient to determine whether a restrictive approach to transfusion can be used without increasing AKI risk. METHODS: In a prespecified kidney substudy of a randomized noninferiority trial, we compared a restrictive threshold for red blood cell transfusion (transfuse if hemoglobin<7.5 g/dl, intraoperatively and postoperatively) with a liberal threshold (transfuse if hemoglobin<9.5 g/dl in the operating room or intensive care unit, or if hemoglobin<8.5 g/dl on the nonintensive care ward). We studied 4531 patients undergoing cardiac surgery with cardiopulmonary bypass who had a moderate-to-high risk of perioperative death. The substudy's primary outcome was AKI, defined as a postoperative increase in serum creatinine of ≥0.3 mg/dl within 48 hours of surgery, or ≥50% within 7 days of surgery. RESULTS:Patients in the restrictive-threshold group received significantly fewer transfusions than patients in the liberal-threshold group (1.8 versus 2.9 on average, or 38% fewer transfusions in the restricted-threshold group compared with the liberal-threshold group; P<0.001). AKI occurred in 27.7% of patients in the restrictive-threshold group (624 of 2251) and in 27.9% of patients in the liberal-threshold group (636 of 2280). Similarly, among patients with preoperative CKD, AKI occurred in 33.6% of patients in the restrictive-threshold group (258 of 767) and in 32.5% of patients in the liberal-threshold group (252 of 775). CONCLUSIONS: Among patients undergoing cardiac surgery, a restrictive transfusion approach resulted in fewer red blood cell transfusions without increasing the risk of AKI.
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