Restricting the transfusion threshold in acute UGIB

Question: When to transfuse in acute upper GI bleed (UGIB)?

Motivation: A common presentation in medicine, and unclear guidelines for when to transfuse. 

Study: 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. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11-21. doi: 10.1056/NEJMoa1211801.

Study design: This study randomized patients with severe UGIB (and hence high rebleed risk) to transfusion when Hb < 7 g/dL (restrictive) and Hb < 9 g/dL (liberal). The study took place in a hospital in Barcelona (so this was not a multi-center study). Patients were transfused 1 u pRBC until they met their transfusion thresholds, and were also followed up with further treatment (endoscopic therapy, PPI, and/or treatment of portal HTN or esophageal varices when indicated). Deviations for clinically appropriate transfusions (such as symptoms, active bleeding, surgical intervention) were also allowed. Primary outcome was rate of death, while secondary outcomes included any further bleeding or complications. Both groups had similar baseline characteristics (including baseline Hb), and were analyzed with intention-to-treat design. (Villanueva et al, 2003)

Results: Rate of mortality at 45 days was lower in the restrictive group (5%) versus the liberal group (9%) with p = 0.02. Subgroup analysis showed that this difference was more dramatic among patients with cirrhosis and Child-Pugh class A or B. Rate of continued bleeding was lower in the restrictive group (10%) versus the liberal group (16%) (p=0.01). Length of stay in the hospital and rate of complications (especially transfusion reactions and pulmonary edema) were also statistically significantly lower in the restrictive versus the liberal group. Note that deviations from transfusion threshold did occur more in the restrictive group, but in <10% of cases. (Villanueva et al, 2003)

Take home point: For patients who present with acute UGIB, setting a restrictive transfusion threshold of Hb < 7 is appropriate. It will, of course, continue to be important to transfuse (as with some of the patients in this study) when otherwise clinically appropriate (i.e. if necessary for surgical/procedural intervention, symptomatic, or severe active bleeding), but trying to use a lower transfusion threshold is a decision that is justified by the evidence presented in this study.