Fewer Transfusions Safe, but Quality of Life May Suffer

Ricki Lewis, PhD

December 17, 2018

Minimizing red blood cell (RBC) transfusions for hospitalized patients with moderate anemia is linked to an increase in prevalence and incidence of anemia at discharge, but not to an increase in the rates of rehospitalization, further transfusions, or mortality at 6 months, a study has found.

Nareg H. Roubinian, MD, MPHTM, of the Division of Research, Kaiser Permanente Northern California, and colleagues reported their findings online December 17 in Annals of Internal Medicine.

However, editorialists point out that the investigation did not consider problems regarding quality of life resulting from having to tolerate anemia in lieu of treating it.

The researchers conducted a retrospective cohort study in which they accessed electronic health record data from Kaiser Permanente for all nonobstetric adults hospitalized from 2010 to 2014. The 21 associated hospitals began introducing blood management programs in 2010. Initiatives included the resolution of anemia prior to surgeries, increased use of cell salvage and hemostatic agents, and blood-sparing interventions during procedures.

Blood management programs were implemented to limit transfusions for moderate anemia (hemoglobin level <10 g/dL but ≥7 g/dL) in response to findings in several randomized clinical trials that showed that outcomes for patients who had received less frequent transfusions were similar to those of patients who had undergone standard transfusion therapy. However, studies may not have taken into account patients' experience of fatigue, weakness, dizziness, exercise intolerance, and other manifestations of persistent anemia.

Roubinian and colleagues assessed effects on limiting transfusions after 6 months from hospital discharge, rather than after 1 month, as in past investigations. The study evaluated 445,371 patients; of 187,440 patients who were hospitalized (23%), moderate anemia was present at the time of discharge in 119,489 patients (27%).

During the 5-year span, the prevalence of moderate anemia at discharge increased from 20% to 25% (relative risk [RR], 1.070; confidence interval [CI], 1.066 - 1.074; P < .001), as did the annual incidence of moderate anemia (RR, 1.048; CI, 1.046 - 1.051; P < .001). From 2010 until 2014, transfusions decreased by 28%, from 39.8 to 28.5 RBC units per 1000 patients (P < .001).

Six months after discharge, the proportion of patients whose moderate anemia had resolved dropped from 42% in 2010 to 34% in 2014; transfusion rates fell from 19% to 17%; and rehospitalization rates fell from 37% to 33% (P < .001 for all three). The mortality rate at 6 months decreased from 16.1% to 15.6% (P = .004) in patients with moderate anemia, a rate similar to that of all other patients.

Patients discharged with moderate anemia were older, sicker, and had been in the hospital longer than patients with mild anemia or normal hemoglobin levels. During the study period, the patients with moderate anemia experienced a small increase in illness severity, comorbidities, and emergency admissions, although surgical admissions declined.

"Our study provides data showing that an increase in anemia persistence after hospitalization did not seem to adversely affect measures of morbidity and mortality in the 6 months after hospital discharge," the researchers conclude. But they call for additional studies to assess effects on anemia-related quality of life in the months after hospitalization for patients in whom transfusions have been minimized.

In an accompanying editorial, Aryeh Shander, MD, from the Icahn School of Medicine at Mount Sinai, New York City, and Lawrence Tim Goodnough, MD, from Stanford University, California, agree that further studies are needed to evaluate the effects of limited transfusions on symptoms and other aspects of quality of life following discharge. They frame the choice between transfusion and its inherent risks vs tolerating persistent anemia as one involving "the lesser of 2 evils.

"With this mindset, we are trapped in a possibly endless quest to find a magical hemoglobin number, below which the risk for anemia becomes greater than the risk for transfusion and, hence, transfusion is recommended," Shander and Goodnough write. Such a strategy would be untenable, they argue, given the diversity of patient populations and comorbidities to consider.

Rather than providing across-the-board transfusions, they call for more personalized evaluation that considers actual oxygen consumption and provides treatments, when appropriate, such as iron supplements, rather than allogeneic RBC transfusion as "the default therapy for anemia." They also point out that the blood management programs mentioned in the article do not consider posthospitalization interventions.

"Anemia is a serious medical condition with substantial ramifications (and certainly not an 'innocent bystander'), and allogeneic blood cannot provide more than a temporary relief — at a potentially hefty price.... Let's increase efforts to prevent and treat anemia properly, rather than requiring patients to tolerate it," the editorial writers conclude.

A limitation of the study is that the results may not be applicable to other populations, such as obstetric and pediatric patients, and to patients who have had organ transplants.

The study was supported by a grant from the National Heart, Lung, and Blood Institute. The researchers and editorialists have disclosed no relevant financial relationships.

Ann Intern Med. Published online December 17, 2018. Abstract, Editorial

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