1.
Effect of restrictive versus liberal transfusion strategies on outcomes in patients with cardiovascular disease in a non-cardiac surgery setting: systematic review and meta-analysis
Docherty AB, O'Donnell R, Brunskill S, Trivella M, Doree C, Holst L, Parker M, Gregersen M, Pinheiro de Almeida J, Walsh TS, et al
Bmj.. 2016;352:i1351.
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Abstract
OBJECTIVE To compare patient outcomes of restrictive versus liberal blood transfusion strategies in patients with cardiovascular disease not undergoing cardiac surgery. DESIGN Systematic review and meta-analysis. DATA SOURCES Randomised controlled trials involving a threshold for red blood cell transfusion in hospital. We searched (to 2 November 2015) CENTRAL, Medline, Embase, CINAHL, PubMed, LILACS, NHSBT Transfusion Evidence Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, ISRCTN Register, and EU Clinical Trials Register. Authors were contacted for data whenever possible. TRIAL SELECTION Published and unpublished randomised controlled trials comparing a restrictive with liberal transfusion threshold and that included patients with cardiovascular disease. DATA EXTRACTION AND SYNTHESIS Data extraction was completed in duplicate. Risk of bias was assessed using Cochrane methods. Relative risk ratios with 95% confidence intervals were presented in all meta-analyses. Mantel-Haenszel random effects models were used to pool risk ratios. MAIN OUTCOME MEASURES 30 day mortality, and cardiovascular events. RESULTS 41 trials were identified; of these, seven included data on patients with cardiovascular disease. Data from a further four trials enrolling patients with cardiovascular disease were obtained from the authors. In total, 11 trials enrolling patients with cardiovascular disease (n=3033) were included for meta-analysis (restrictive transfusion, n=1514 patients; liberal transfusion, n=1519). The pooled risk ratio for the association between transfusion thresholds and 30 day mortality was 1.15 (95% confidence interval 0.88 to 1.50, P=0.50), with little heterogeneity (I(2)=14%). The risk of acute coronary syndrome in patients managed with restrictive compared with liberal transfusion was increased (nine trials; risk ratio 1.78, 95% confidence interval 1.18 to 2.70, P=0.01, I(2)=0%). CONCLUSIONS The results show that it may not be safe to use a restrictive transfusion threshold of less than 80 g/L in patients with ongoing acute coronary syndrome or chronic cardiovascular disease. Effects on mortality and other outcomes are uncertain. These data support the use of a more liberal transfusion threshold (>80 g/L) for patients with both acute and chronic cardiovascular disease until adequately powered high quality randomised trials have been undertaken in patients with cardiovascular disease. REGISTRATION PROSPERO CRD42014014251.Copyright Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
PICO Summary
Population
Patients with cardiovascular disease not undergoing cardiac surgery (11 randomised controlled trials, n= 3,033).
Intervention
Restrictive transfusion strategy (n= 1,514).
Comparison
Liberal transfusion strategy (n= 1,519).
Outcome
The pooled risk ratio for the association between transfusion thresholds and 30-day mortality was 1.15 (95% confidence interval (CI): 0.88 to 1.50), with little heterogeneity (I2= 14%). The risk of acute coronary syndrome in patients managed with restrictive compared with liberal transfusion was increased (nine trials; risk ratio: 1.78, 95% CI: 1.18 to 2.70, I2= 0%).
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Safety of blood donation from individuals with treated hypertension or non-insulin dependent type 2 diabetes - a systematic review
Stainsby D, Brunskill S, Chapman CE, Doree C, Stanworth S
Vox Sanguinis. 2010;98((3 Pt 2):):431-40.
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Editor's Choice
Abstract
BACKGROUND AND OBJECTIVES This systematic review was aimed at finding evidence for the safety of blood donation by individuals with treated hypertension or type 2 diabetes. It was undertaken as part of a wider project to re-evaluate exclusion criteria for UK blood donors with a view to increasing eligibility. MATERIALS AND METHODS Searches were undertaken in the Cochrane Library to 2008, MEDLINE (1950 onwards), EMBASE (1974 onwards), CINAHL (1982 onwards), BNID (1994 onwards), the NHSBT SRI Handsearching Database and the Web of Science (all years) to February 2008. Planned analysis was largely descriptive. RESULTS We identified only 16 relevant papers. None of the identified studies directly addressed the review questions and methodological appraisal highlighted a number of deficiencies. However all included papers provided contributory data and the findings were consistent. No study found any evidence of increased risk to homologous (allogeneic) or autologous blood donors with treated hypertension or with raised baseline systolic blood pressure up to 200 mmHg. We found very few data relating to blood donation by diabetic subjects. CONCLUSIONS No identified study indicated that raised baseline blood pressure level, treated hypertension or diabetes was predictive of increased adverse reactions in blood donors but the level of overall evidence was limited. This is the first attempt to systematically review a donor area as part of an approach to change longstanding practice recommendations, and may have implications for other recommendations for changes in donor acceptance criteria. [References: 20]
PICO Summary
Population
Blood donors with treated hypertension or type 2 diabetes (16 studies).
Intervention
Systematic review to ascertain the evidence for safety of blood donation by blood donors with treated hypertension or type 2 diabetes.
Comparison
Outcome
None of the identified studies directly addressed the review questions and methodological appraisal highlighted a number of deficiencies. All included papers provided contributory data and the findings were consistent. No study found any evidence of increased risk to homologous (allogeneic) or autologous blood donors with treated hypertension or with raised baseline systolic blood pressure up to 200 mmHg. Very few data relating to blood donation by diabetic subjects was found.